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The skeleton of the sponge is interconnected spinel cheap 40mg lasix fast delivery. The holes are filled with interconnected calcium phosphate (Figs buy 40 mg lasix otc. The local chemistry at the tissue implant is dominated by the calcium phosphate because the spinel is insoluble buy generic lasix 100 mg on-line. The high solubility of the calcium phosphate in Guided Diaphysis Regeneration 199 Table 1 Properties of the Composite Composition: Ca3(PO4)2 and MgAl2O4 Compressive strength 199 MPa Tensile strength 70 MPa Young’s modulus 114 GPa Reversible thermal expansion 10 effective 40mg lasix. The composite is manufactured from finely powdered tricalcium phosphate and magne- sium-aluminate spinel discount lasix 100 mg fast delivery. The powders are mixed with dispersants and organic binders and formed into suitable shapes by extrusion, casting, or pressing. Guided Bone Replacement This experiment has been reported in more detail previously [23,24]. This presentation provides additional understanding of the results that were obtained after the death of the dog from natural causes. The implant was made to comply with the considerations discussed above as an Osteocer- amic tubular cylinder with end notches for tissue attachment, longitudinal grooves to induce critical bone regeneration across the implant, and holes connecting the grooves to the medullary cavity for blood supply to bone induced to grow in the grooves (Fig. Instead, the dove-tailed end notches were large enough to be filled with bone and with normal endosteal and periosteal blood supply to form and maintain bone Figure 1 Energy dispersive x-ray map of the polished Osteoceramic showing the Ca and P phase separated from the Mg and Al phase. Figure 2 Surface of the Osteoceramic polished to produce relief of the hard, fine-grained MgAl2O4 relative to the soft larger Ca3PO4 grains. Figure 3 Structure of the spinel skeleton when the Ca3PO4 is removed with EDTA. Guided Diaphysis Regeneration 201 Figure 4 Geometry of a guided bone replacement implant showing the external longitudinal grooves for guiding the cortex and the radial holes for blood vessels from the medullary supply. After dissolution of calcium phosphate at the surface the pores in the spinel are the same size as the dissolved calcium phosphate. They are smaller than 100 m so Haversian systems cannot grow into them. However, calcium phosphates could be deposited at the surface by osteoblast activity. The longitudinal grooves are provided to guide cortical bone to regenerate across the implant. If this is successful, and a blood supply is encouraged by the regeneration grooves, then cortical bone strong enough to surround and support the implant should be possible. These experiments were conducted to test the hypotheses that tissue attachment could be achieved and that the grooves would guide the regeneration process. Experimental Evaluation Seven implants with variation in wall thickness, size of the end notches, size of the longitudinal grooves, and placement of the radial holes were implanted. The number of notches was set arbitrarily at six, enough so that random orientation would provide fixation for bending forces (Table 2). One implant was placed in one femur of each mongrel dog. The procedures, and the justification for the research, were approved by the Iowa State University Committee on Animal Care. Circlage wire was used to attach the implant to the bone plate. One method was to pass a single wire through the axial holes at the center of the implant, bending it around the bone plate and twisting the wire tight enough to stabilize the implant without breaking it. A second way was to circle the implant and the plate with the wire and twist it to stabilize the wire. The third method was to use two circling wires, placed at about one-third of the length from each end. The stiffer wire was more difficult to 202 Olson et al. Table 2 Dimensions of the Bone Bridges Transverse Outside Inside Dovetail hole width Implant Inside Outside tenon tenon slot (mm) Dovetail Dog length diameter diameter width width width slot depth number (mm) (mm) (mm) (mm) (mm) (mm) (d1 d 2) (mm) 1 27.

A 52-year-old man presents to your office for his yearly physical examination lasix 40mg otc. He is completely asymp- tomatic and is tolerating his single blood pressure medication well 40mg lasix amex. On review of systems order lasix 100mg visa, the patient states that for several weeks buy cheap lasix 40mg, he has had severe pruritus after showering and that lately his face has been feeling “flushed buy 40mg lasix otc. Physical examination is significant only for facial plethora and moderate nontender splenomegaly. CBC reveals a WBC of 13,000/mm3 with 6% basophils, a hematocrit of 60%, and a platelet count of 640,000/mm3. Hemoglobin oxygen satura- tion on room air is 98% with a normal respiratory rate. Which of the following statements regarding basophils or basophilia is true? Thrombocytosis is commonly associated with splenectomy, but splenectomy has no association with basophilia B. Basophilia is defined as a basophil count greater than 500/mm3 C. Basophilia is seen in myeloproliferative disorders (MPDs) such as chronic myelogenous leukemia (CML), polycythemia vera (PV), and myeloid metaplasia, as well as in some hemolytic anemias and Hodgkin disease D. Granules in the basophil do not contain histamine Key Concept/Objective: To understand basophil physiology and the clinical significance of basophilia Basophilia (i. The basophil count can also be increased in patients with ulcerative coli- tis or varicella infection. Although basophils and mast cells are involved in immediate hypersensitivity reactions and basophils are often seen in areas of contact dermatitis, basophilia is not seen in patients with these disorders. Most, if not all, of the circulating his- tamine in the body is synthesized by the basophil and stored in its granules. Degranulation causes the release of histamine, which mediates many immediate hypersensitivity effects and which, because it is a potent eosinophil chemoattractant, draws eosinophils to the site of degranulation. Other substances that are released on basophil degranulation include additional eosinophil chemotactic factors and a variety of arachidonic acid metabolites, the most important of which is leukotriene C4. You are asked to consult on a case involving a 26-year-old man who developed leukocytosis after a motorcycle accident 3 days ago. The patient has multiple fractures of the pelvis and lower extremities, extensive soft-tissue injury, and aspiration pneumonia. His leukocyte count was 35,000 on admission and has subsequently ranged up to 50,000. Currently, the patient is sedated and is on a ventilator. Physical examination is remarkable for right lower lateral consolida- tion, ecchymoses of the lower extremities, and the absence of hepatosplenomegaly. No myelocytes or metamyelocytes are noted, and there is no elevation of the basophil or eosinophil count. The leukocyte alkaline phosphatase (LAP) score is 140 µm/L. Which of the following cannot be the cause of this patient’s elevated neutrophil count? Cytokine release Key Concept/Objective: To understand the causes of the leukemoid reaction and distinguish them from malignant causes The term leukemoid reaction is used to describe a profound leukocytosis (generally defined as a leukocyte count exceeding 25,000 to 30,000/mm3) that is not leukemic in eti- 20 BOARD REVIEW ology. Leukemoid reactions are the response of normal bone marrow to cytokine release by lymphocytes, macrophages, and other cells in response to infection or trauma. In a leukemoid reaction, the circulating neutrophils are usually mature and are not clonally derived. The major differential diagnosis is with regard to CML. Leukemoid reactions should also be distinguished from leukoerythroblastic reactions: the presence of immature white cells and nucleated red cells in the peripheral blood irrespective of the total leuko- cyte count. Although less common than leukemoid reactions in adults, leukoerythroblas- tosis reflects serious marrow stimulation or dysfunction and should prompt bone marrow aspiration and biopsy, unless it occurs in association with severe hemolytic anemia, sepsis in a patient with hyposplenism, or massive trauma.

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If the workup for the presence of a tumor is negative buy cheap lasix 40 mg on-line, further workup for CAH would be indi- cated cheap lasix 100 mg with mastercard. A 38-year-old man presents to your clinic complaining of hair loss generic lasix 40 mg online. He reports that the hair loss began several years ago but is more noticeable now generic lasix 100 mg with visa. His hair has been thinning out on the sides as well as on the top of his head quality 100 mg lasix. He reports that several family members have the same problem. Which of the following is the most appropriate therapy for this patient’s condition? Topical 2% minoxidil applied to the scalp twice daily B. Medium- to high-potency topical steroids applied daily C. Topical immunotherapy with the sensitizing chemical diphencyprone D. It results from a genetically determined end-organ sensitivity to androgens. It is often referred to as common baldness, male-pattern alopecia, and female-pattern alopecia. Androgenetic alopecia affects at least 50% of men by 50 years of age and 50% of women by 60 years of age. Men have more androgen than women and therefore are usually affect- ed earlier and more severely. Male-pattern alopecia often starts in persons between 15 and 25 years of age. Male-pattern alopecia has two characteristic components, bitemporal reces- sion and vertex balding, which in pronounced cases can progress to complete balding of the crown. Depending on the severity of the condition, management of androgenetic alopecia ranges from watchful inactivity to medical and surgical treatment; a hairpiece or wig may be used in the most refractory cases. Minoxidil is applied twice daily with a drop- per, spread over the top of the scalp, and gently rubbed in. It produces visible hair growth in approximately one third of male and female patients, fine-hair growth in approximately one third, and no growth in approximately one third. It is more effective as a preventive agent, retarding hair loss in approximately 80% of patients. Topical steroid therapy, topical immunotherapy, and use of anthralin cream are therapeutic choices for the treatment of alopecia areata. A 42-year-old woman presents to the walk-in clinic complaining of hair loss. She notes the hair loss mostly on the top of her head but also on the sides. She reports a history of hypertension and diabetes but is currently on no medications. On review of systems, she reports some menstrual irregularities but is otherwise without complaint. She has tried some over-the-counter products for facial hair growth, but they have not helped the hair loss on her scalp. She would like to try something “prescription strength. Begin therapy with topical 2% minoxidil applied twice daily and see her again in 3 to 6 months B. Begin daily therapy with ethinyl estradiol-ethynodiol diacetate and see her again in 6 weeks C. Explain the risks and benefits of hormone replacement therapy for perimenopausal symptom relief and see her again in 1 to 2 months D. Screen the patient for hyperandrogenism and see her again in 1 to 2 weeks Key Concept/Objective: To be able to differentiate simple androgenetic alopecia from hyperandro- genism The constellation of symptoms seen in this patient should raise concern about the possi- bility of excess circulating androgen. The diagnosis of androgenetic alopecia is usually obvious from the clinical pattern of hair loss from the top of the head. In some men, a female pattern of alopecia causes diagnostic confusion but has no other significance. The virilism indicates significant hyperandrogenism, the cause of which must be identified and treated.

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Close examination reveals that MLD is more difficult because it involves manual techniques that are not used in classical massage generic lasix 40mg line. Stationary circles technique: In this technique purchase lasix 100mg line, the fingers are placed flat on the skin and moved in the same place as stationary circles cheap lasix 100 mg free shipping. Each of these circles is performed with a smooth increase of pressure and a smooth decrease of pressure into the tissue cheap 100mg lasix mastercard. Pump technique: In this technique order lasix 40 mg with amex, the palms face downward. The thumb and fingers move together in the same direction, moving the skin in oval circles. Scoop technique: In this technique, the palm is facing upward. Rotary technique: This technique is used on relatively flat areas of the body and consists of various individual movements. Proper MLD consists of a combination of round or oval, small or large, and deep or shallow circular movements; it: 1. Stimulates the microcirculation, improving edema and cellular nutrition 2. Requires only thirty to forty minutes of treatment 287 288 & LEIBASCHOFF 3. Does not require the use of creams—it is important to remember that MLD does not use creams, only the hands 6. Moves lymph and high protein from the interstitium into the small lymphatic vessels 8. Requires applying lighter pressure for softer tissues (Fig. Figure 1 Maneuvers of MLD in the legs (A–C) and in the arms (D) after mastectomy for breast cancer. MANUAL LYMPHATIC DRAINAGE & 289 The Vodder method of MLD is a technique used to stimulate the movement of fluids in the tissues (5). The gentle, rhythmic, pumping massage movements follow the direction of lymph flow and produce rapid results. This massage technique is focused on tissue and lymphatic detoxification and is proposed as an important means of preventing cellulite recurrence (6). MLD periodic cycles are recommended to maintain tissues free of lymph stasis. With the introduction of endermology, the device itself carries out drainage and promotes secondary detoxification, connective tissue stimulation, and a neurophysiologic response. It reduces the need for compression garments in the treatment of lymphedema. The bimonthly or monthly inclusion of Vodder’s MLD may be extremely useful for cosmetic as well as medical purposes. Sistema Linfatico de los miembros inferiors, Linfologia 4, Buenos Aires, 2002. Vodder’s Manual Lymph Drainage, Renato Kasseroller Md, 1998. In 1970, a group of American dermatologists discovered that by applying an intense electrical impulse for a short time at an adequate wave length, a change in polarization of the cellular membrane occurred, which could be used to promote a kind of cellular ‘‘pulsation. Once they are formed, these channels stay open for a relatively long time—several seconds. This method was named ‘‘electroporation’’ and was used, with special techniques, in the transdermic treatment of melanomas. Electroporation with high voltage is the only system that can introduce substances of high molecular weight transdermally. Over 4000 published scientific reports demonstrate the actions and possible uses of the method (9). Despite the very similar name, ‘‘dermoelectroporation’’ is different, because this new method works with lower voltages in comparison to ‘‘electroporation. Why does the new method work well only after dermabrasion of the horny layer? The answer can be that the high voltage in classical electroporation produces only partly poration of the horny layer and partly poration of the dermis (with the residual energy after having perforated the horny layer). Dermoelectroporation eliminates the need for high voltage because the epidermal horny layer is eliminated with microdermabrasion and so the voltage necessary to porate the dermis is lower.

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