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They increment red blood cell deformability generic kamagra 100mg on-line, diminish vascular permeability discount kamagra 100mg free shipping, and improve vas- cular wall tonus purchase 50 mg kamagra. The methylxanthine ‘‘pentoxyfylline’’ improves microcirculatory perfusion through its effect on hematological factors such as erythrocyte shape generic kamagra 50mg online, platelet aggregation purchase kamagra 50mg visa, and plasma fibrinogen concentra- tion. It has been utilized for peripheral vascular disease treatment with significant benefit. For the treatment of cellulite (20), it has been used transdermally with other drugs, making its evaluation difficult. It acts as an alpha-adrenergic receptor agonist of the smooth muscle of veins and therefore reduces vascular permeability. The main active ingredients are saponins, ruscogenin, and neororuscogenina (21). Asiatic centella extract, both topically and systemically, has been used for treating cel- lulite and has been demonstrated through capillaroscopy to have an effect on the microcir- culation in patients with chronic venous insufficiency, who were treated for venous ulcers (22). Chemically consisting of 40% asiaticosideo, 30% madecassic acid, and 30% Asiatic acid, topical and systemic Asiatic centella have been shown to be harmless by toxicity tests. Asiatic centella also acts in vitro on fibroblasts, stimulating collagen and mucopolysacchar- ide synthesis. This compound also acts as an anti-inflammatory agent, which may be ben- eficial in protecting dermal and subcutaneous structures from inflammatory cell injury (19). Silicium is a structural element of connective tissue, which regulates and normalizes cellular metabolism and cellular division. In the microcirculation, it modifies venous capil- lary and lymphatic permeability and, in the fatty tissue, it stimulates cAMP synthesis as well as triglyceride hydrolysis, likely activating adenylcyclase in the cellular membrane (23). For this reason, it has been used in topical cellulite treatment products. Chofitol or artichoke (Cynara scolymus) is a member of Arteraceae family, and it is found in northern Mediterranean soil. Its principal active chemical constituents are numer- ous enzymes, cynarin, ascorbic acid, caffeoylquinic acid derivates, and flavonoids. It has an antiedematous and diuretic effect, as well as a stimulating effect on the circulation (19). Common ivy (Hedera helix) is a phytomedicine that grows in places with rich soil, sun, or shade. The parts of the plant used are dried leaves and stems. The leaves have flavonoids such as rutosid and rutinosid, and saponins such as hederin, hederacosid, and hederagenin (19,24). The fruits have saponins, especially hederin, and the trunk has gomoresins and sapo- nins. All saponins improve venous and lymphatic drainage and reduce edema. One of these compounds, hederin, also has an analgesic and anti-inflammatory effect. It has vasoconstric- tive and antiexudative properties and can also reduce capillary permeability. It increases cir- culation and therefore assists drainage of the infiltrated tissue and reduces inflammation. Ground ivy (Glechoma hederaceae) is from the Lamiaceae family and is also used in anticellulite treatment. The main constituents are flavonoids, triterpenoids, and phenolic acids. It grows in moist soil in Europe, especially the Caucasus, and in North America (19). Indian or horse chestnut (Aesculus hippocastanum) belongs to the Hippocastanaceae family. The seeds and the shells are used in the elaboration of the standard extract (25). The active ingredients contained in the seeds are triterpenoid saponins, such as escin and aesculin, and flavones, coumarins, and tannins (25), with anti-inflammatory and anti- edematous properties (26). Escin is the principal component of horse chestnut, and it has the capacity to reduce lysosomatic enzyme activity by up to 30%, probably by stabilizing 164 & HEXSEL ET AL. Sweet clover (Melilotus officinalis) is a plant from the Fabaceae family. The active ingredient is contained in the flowers and leaves.

Arch Neurol 58: 1290–1291 Love S buy 50 mg kamagra free shipping, Coakham HB (2001) Trigeminal neuralgia order kamagra 100 mg line. Brain 124: 2347–2360 Schmidt F buy kamagra 50 mg without a prescription, Malin JC (1986) Nervus trigeminus (V) trusted kamagra 100 mg. In: Schmidt D buy kamagra 50 mg low price, Malin JC (eds) Erkrankun- gen der Hirnnerven. Thieme, Stuttgart, pp 124–156 53 Abducens nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy CSF + MRI CT Angiography Fig. This patient suffered a fall with subsequent head trauma Somatic motor, innervation of lateral rectus muscle Quality The abducens nucleus is located in the pontine tegmentum close to the Anatomy midline, and ventral to the fourth ventricle. Axons from cranial nerve VII loop around the abducens nucleus, forming the bulge of the fourth ventricle. Axons from the abducens nucleus course ventrally through the pontine tegmentum to emerge from the ventral surface of the brainstem at the junction of the pons and the pyramid of the medulla. The nerve runs anterior and lateral in the subarach- noid space of the posterior fossa, to piercing the dura lateral to the dorsum sellae of the sphenoid bone. The nerve continues forward between the dura and the apex of the petrous temporal bone. Here it takes a sharp right angle, bending over the apex of the temporal bone to enter the cavernous sinus. The nerve lies lateral to the carotid artery, and medial to CN III, IV, V1 and V2. Finally, the abducens nerve enters the orbit at the medial end of the superior orbital fissure. Patients report binocular horizontal diplopia that worsens when looking in the Symptoms direction of the paretic lateral rectus muscle and when looking at distant objects. Abduction of the affected eye is highly reduced or impossible, while gaze to the unaffected side is normal (see Fig. Pathogenesis Lateral rectus paralysis is the most frequently encountered paralysis of an extraocular muscle. Topographically: Nuclear: Infarction, tumor, Wernicke’s disease, Moebius and Duane’s syndrome (rare). Subarachnoid: Meningitis, subarachnoid hemorrhage, clivus tumor (men- ingioma, chordoma), trauma, basilar aneurysm. Petrous apex: Mastoid infection, skull fracture, raised ICP, trigeminal Schwannoma. Uncertain: Microvascular infarction, migraine Metabolic: Rarely diabetes Toxic: Vincristine therapy Vascular: Aneurysms of the posterior inferior cerebellar, basilar or internal carotid arteries Infections: CMV encephalitis Cryptococcal meningitis Cysticercosis HIV Lyme disease Syphilis Tuberculosis Ventriculitis of the fourth ventricle Inflammatory-immune mediated: Vasculitis, sarcoidosis, systemic lupus erythematosus (SLE) Trauma: Fractures of the base of the skull Neoplastic: Abducens nerve tumor Cerebellopontine angle tumor Clivus tumor Leptomeningeal carcinomatosis Leukemia Metastasis (base of the skull) Congenital: Duane’s syndrome 55 Compressive: Lesions of the cavernous sinus (e. Convergence spasm Differential diagnosis Duane’s syndrome Internuclear ophthalmoplegia Myasthenia gravis Pseudo VI nerve palsy (thalamic and subthalamic region) Thyroid disease Treatment is dependent upon the underlying cause. Therapy The most frequent “idiopathic” type in adults usually remits within 4–12 weeks. Prognosis Galetta SL (1997) III, IV, VI nerve palsies. References American Academy of Neurology, Boston, pp 145-33–145-50 Gurinsky JS, Quencer RM, Post MJ (1983) Sixth nerve ophthalmoplegia secondary to a cavernous sinus lesion. J Clin Neuro Ophthalmol 3: 277–281 Lee AG, Brazis PW (2000) Neuro-ophthalmology. In: Evans RW, Baskin DS, Yatsu FM (eds) Prognosis of neurological disorders. Oxford University Press, New York Oxford, pp 97–108 Robertson RM, Hines JD, Rucker CW (1970) Acquired sixth nerve paresis in children. Arch Ophthalmol 83: 574–579 Rucker CW (1966) The causes of paralysis of the third, fourth, and sixth cranial nerves. Am J Ophthalmol 62: 1293–1298 Rush JA, Younge BR (1981) Paralysis of cranial nerves III, IV and VI. Arch Ophthalmol 99: 76–79 56 Facial nerve Genetic testing NCV/EMG Laboratory Imaging Clinical exam ++ + MRI Taste Hearing Fig. Facial nerve: 1 Posteri- or auricular nerve, 2 Mandibu- lar branch, 3 Buccal branch, 4 Zygomatic branch, 5 Temporal branch, 6 Parotid gland Fig. Facial nerve palsy: This patient suffered from a right sid- ed Bell’s palsy, which resulted in a contracture of the facial muscles. Note the deviated mouth 57 Stapedius, stylohyoid, posterior belly of disgastric, muscles of facial expression, Qualities including buccinator, platysma, and occipitalis muscles.

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Normal-sized heart Key Concept/Objective: To know the risk factors associated with failed synchronized DC cardioversion 14 BOARD REVIEW Although success rates are high with DC cardioversion buy 50mg kamagra amex, a number of risk factors for car- dioversion failure have been identified generic 100mg kamagra visa. These include longer duration of AF (notably buy kamagra 50 mg on-line, longer than 1 year) generic kamagra 50mg amex, older age order 100mg kamagra with mastercard, left atrial enlargement, cardiomegaly, rheumatic heart dis- ease, and transthoracic impedance. Pretreatment with amiodarone, ibutilide, sotalol, fle- cainide, propafenone, disopyramide, and quinidine have been shown to increase DC car- dioversion success rates. A 29-year-old white woman presents to the emergency department with the complaint that her heart is “racing away. She also reports having had similar episodes in her life, but she says they never lasted this long and that they usually abated with a simple cough. On examination, the patient’s pulse is regular at 175 beats/min. Electrocardiography reveals atrioventricular nodal reentry tachycardia (AVNRT). Which of the following statements regarding AVNRT is false? Most cases of AVNRT begin with a premature ventricular contraction (PVC) ❏ B. Long-term therapy includes beta blockers, calcium channel blockers, and digoxin ❏ D. Catheter ablation for AVNRT is clearly the procedure of choice for patients in whom drug therapy fails Key Concept/Objective: To understand the pathogenesis of and therapy for AVNRT The normal AV node has a single transmission pathway. In two to three persons per 1,000 population, however, the AV node has both a normal (fast) pathway and a second (slow) pathway. In such persons, the sinus impulse is ordinarily transmitted over the fast path- way to the ventricle, and slow-pathway conduction is preempted. However, if an atrial pre- mature complex (APC) occurs at a critical point in the conduction cycle, the impulse can become blocked in the fast pathway, thus allowing for anterograde (forward) conduction over the slow pathway and retrograde (backward) conduction over the fast pathway. This may produce a single echo beat (a beat that returns to the chamber of origin), or it may stabilize into a circus-movement tachycardia. The diagnosis of AVNRT can usually be made by careful analysis of the 12-lead ECG. Because retrograde conduction over the AV node is occurring more or less simultaneously with anterograde conduction to the ventricles, the P wave is either buried within the QRS complex or inscribed just after the QRS. AVNRT may respond to carotid sinus massage but is highly responsive to intravenous adenosine, beta blockers, or calcium channel blockers. If carotid massage fails to convert supraven- tricular tachycardia, the drug of choice is intravenous adenosine, which is effective in 95% of cases. A wide variety of drugs have proved effective for controlling episodes of AVNRT, including beta blockers, calcium channel blockers, and digoxin. Long-term drug therapy is associated with frequent recurrences and adverse effects, however. Catheter ablation for AVNRT has proved so safe and effective that it is clearly the procedure of choice for patients in whom drug therapy fails. Moreover, it can be offered to those patients with milder symptoms who prefer to avoid long-term drug therapy. A 19-year-old man presents to the emergency department complaining of dyspnea and palpitations of acute onset. He has been short of breath for 2 hours now but denies having any chest pain. He has never had these symptoms before, and he denies having any cardiac disorders in the past. He is taking no med- 1 CARDIOVASCULAR MEDICINE 15 icines and has no significant family history of sudden cardiac death or arrhythmias. On examination, the patient is tachycardic but the heartbeat is regular. His blood pressure is 110/72 mm Hg, and he is afebrile. ECG reveals a narrow complex tachycardia with a retrograde P wave noted in the ST segment. You diagnose the patient as having atrioventricular reentry tachycardia (AVRT). Which of the following statements regarding AVRT is true? Because of the location of the reentrant pathway, catheter ablation is contraindicated ❏ C.

Analisi qualitativa e quantitative sperimentale di ionoforesi (Morphological order kamagra 100mg fast delivery, qualitative and quantitative analysis of experimental ionophoresis) order 100 mg kamagra with mastercard. In vivo evaluation of transdermal delivery of collagen and lidocaine by a novel system of dermoelectroporation buy 100mg kamagra. Enhancement of transdermal drug delivery: chemical and physical approaches discount kamagra 50 mg on line. Chemical enhancement of percutaneous absorption in relation to stratum corneum structural alteration discount 100mg kamagra with visa. Electroporation of mammalian skin: a mechan- ism to enhance transdermal drug delivery. Transdermal delivery of macromolecules using skin electro- poration. The role of dermoelectroporation in the aesthetic medicine. Job’s Book of Brasilian Congress of Aesthetic Medicine, Sao Paulo, June 9–12, 2004. Job’s Book of International Congress of Aesthetic Medicine and Cosmetic Surgery, Lisboa, September 12–16, 2004. Job’s Book of Italian Congress of ‘‘Derma- tologists of Great Greece,’’ Vibo Valentia, Italy, October 6–9, 2004. This treatment slowly breaks down fatty deposits with subcutaneous injections of an adipocyte-dissolving for- mula. While it is in its infancy in North America, it has been practiced in Europe and South America for over 10 years. Despite the fact that lipodissolve injectors outside the United States tout its benefits based on their favorable experiences, there exists a consider- able amount of healthy skepticism in the American cosmetic medical community concern- ing this procedure. This is mainly due to the paucity of scientific literature demonstrating the histopathology, mechanism of action, and detailed measurable clinical results. This is simi- 1 lar to the situation that pioneering practitioners using Botox for cosmetic purposes found themselves in during the early 1990s. Lipodissolve injections are suitable for nonobese patients with localized fat accumu- lation, which cannot be reduced with appropriate diet or sincere efforts at exercise. Lipo- dissolve injections do not result in weight loss; lipodissolve injections modify body contours. The ideal patient has a body mass index (BMI) of less than 25. Lipodissolve is not a substitute for liposuction; it is an alternative to liposuction for smaller areas of fat accumulation in a patient who prefers a less invasive procedure. It is the author’s opi- nion that liposuction is a more cost-effective and efficient procedure than lipodissolve for larger fatty deposits. The active ingredients of the lipodissolve formula are a mixture of phosphatidylcho- line (PC), a natural substance derived from soybean lecithin, and deoxycholate (DC), a bile salt. Aventis Pharma (part of the Sanofi-Aventis Group, Paris, France), which is the third largest pharmaceutical company in the world, markets a PC/DC preparation 1 1 under the trade names Lipostabil and Essentiale in Europe (primarily Germany and 1 Italy), Russia, and South America. The Lipostabil brand contains 5% PC (50 mg/mL) 1 and 4. Lipostabil is not sold in the United States or Canada. PC is commonly known as lecithin, and the commercial preparations of purified PC are derived from soybean lecithin, rather than egg yolk. PC is composed of choline, phosphate, and two fatty acids (Fig. This is the primary consti- tuent of the bilipid cell membrane. PC is involved in the regulation of lipid metabolism (1,2), and is marketed by Aventis as an injectable intravenous infusion to lower cholesterol and triglycerides, under the name LIPODISSOLVE FOR BODY SCULPTING & 303 1 1 Lipostabil. Lipostabil is also used in the treatment of hepatitis (3–5) and cardiovascu- lar atheromatous diseases in Europe and Russia (2,6).

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