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By X. Gnar. Globe Institute of Technology.

Clinical observations cheap 120 mg silvitra overnight delivery impotence under 40, circumference of the thighs and hips purchase 120 mg silvitra otc erectile dysfunction caused by spinal cord injury, plicometry, USE OF TRIACTIVETM IN THE TREATMENT OF CELLULITE & 191 skin elasticity, and thermography were recorded. All patients showed an increase in skin tone and a reduction in the circumference of the areas treated. Weiss, associate professor of TM dermatology at Johns Hopkins School of Medicine, uses TriActive during liposculpture operations. He believes that the use of this device helps evenly distribute the anesthetic fluid in the treatment areas. Although not scientifically proven, it is also believed that TM diode lasers penetrate the fat cells and assist their ability to rupture. TriActive can also TM be used after liposuction to improve results. We have found that the use of TriActive in conjunction with liposuction improves cosmetic results and noted a marked improvement TM in irregularities when TriActive is performed after liposculpture. We believe that the TM TriActive device is able to target and improve dystrophic adipose cells. Once this intensive phase of treatment is finished, the maintenance phase consists of one to two treatments per month. A separate protocol exists for gynecoid and android women. However, only the gynecoid protocol will be reviewed as it is the most frequently used. Each phase should be repeated three times, unless otherwise noted. Any area to be treated should be free of any lotions and sunscreens. In the initial phase, the abdominal and inguinal lymph nodes are treated. This is followed by the digestive phase used to stimulate the digestive system. The subsequent drain- ing phase involves transverse movements from the inner knees and continues until the entire thigh is completed. The supine treatment is completed by re-treating the inguinal lymph nodes. The patient is then placed in a prone position and the initial phase is repeated with the stimula- tion of the posterior inguinal lymph nodes. A transverse motion should be carried out from the distal thigh to the proximal thigh and followed by a longitudinal motion, first on the thigh (starting from the distal part) and then on the lower leg (starting from the final part) for two or three passages. Transversal and linear movements on the buttocks must be performed. Draining action is performed on the lymph nodes in the region between the groin and the inner thigh. To reactivate the vascular pump of the foot, the handpiece is passed over the sole of the foot in a transverse manner, starting from the heel; two to four aspirations are caried out at each point, taking more time on the heel. To tone the buttocks, the patient is repositioned in the supine position and the abdominal and inguinal lymph nodes are re-treated. Andrea Pelosi conducted a study subsequent to that by Nicola Zerbinati using the above protocol, which he had designed and perfected. We performed a study to evaluate the combination of active and passive mechanisms in the treatment of cellulite. Subjects consisted of 11 female patients, all of whom had cellulite on the thighs and/or hips. Prior to treatment (T0), subjects were weighed and height measured to determine BMI. A tape measure was used to measure the circumference of the patient’s hip and thigh. Photographs were taken using standardized lighting, including anterior, lateral, and posterior views of treatment areas.

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These are not always tem © 2006 by Taylor & Francis Group cheap silvitra 120mg otc erectile dysfunction pills at gnc, LLC Functional Systems 115 Ascending reticular activating system (ARAS) Locus ceruleus Lateral group Medial group Raphe nuclei Reticulo-spinal tracts FIGURE 42A: Reticular Formation 1 — Organization © 2006 by Taylor & Francis Group purchase 120mg silvitra visa erectile dysfunction ultrasound treatment, LLC 116 Atlas of Functional Neutoanatomy FIGURE 42B located within the core region. These include the periaq- ueductal gray and the locus ceruleus. RETICULAR FORMATION 2 The periaqueductal gray of the midbrain (for its location see Figure 65 and Figure 65A) includes neurons that are found around the aqueduct of the midbrain (see RETICULAR FORMATION: NUCLEI also Figure 20B). This area also receives input (illustrated In this diagram, the reticular formation is being viewed but not labeled in this diagram) from the ascending sen- from the dorsal (posterior) perspective (see Figure 10 and sory systems conveying pain and temperature, the antero- Figure 40). Various nuclei of the reticular formation, RF, lateral pathway; the same occurs with the trigeminal sys- which have a significant (known) functional role, are tem. This area is part of a descending pathway to the spinal depicted, as well as the descending tracts emanating from cord, which is concerned with pain modulation (as shown some of these nuclei. Functionally, there are afferent and efferent nuclei in The locus ceruleus is a small nucleus in the upper the reticular formation and groups of neurons that are pontine region (see Figure 66 and Figure 66A). In some distinct because of the catecholamine neurotransmitter species (including humans), the neurons of this nucleus used, either serotonin or noradrenaline. The afferent and accumulate a pigment that can be seen when the brain is efferent nuclei of the RF include: sectioned (prior to histological processing, see photograph of the pons, Figure 66). Output from this small nucleus is • Neurons that receive the various inputs to the distributed widely throughout the brain to virtually every RF are found in the lateral group (as discussed part of the CNS, including all cortical areas, subcortical with the previous illustration). In this diagram, structures, the brainstem and cerebellum, and the spinal these neurons are shown receiving collaterals cord. The neurotransmitter that is used by these neurons (or terminal branches) from the ascending ante- is noradrenaline and its electrophysiological effects at var- rolateral system, carrying pain and temperature ious synapses are still not clearly known. It has been implicated in reticular formation, at various levels. These a wide variety of CNS activities, such as mood, the reac- cells project their axons upward or downward. The nucleus gigantocellularis of the medulla, The cerebral cortex sends fibers to the RF nuclei, and the pontine reticular nuclei, caudal, and including the periaqueductal gray, forming part of the oral portions, give rise to the descending tracts cortico-bulbar system of fibers (see Figure 46). The nuclei that emanate from these nuclei — the medial that receive this input and then give off the pathways to and lateral reticulo-spinal pathways, part of the the spinal cord form part of an indirect voluntary motor indirect voluntary and nonvoluntary motor sys- system — the cortico-reticulo-spinal pathways (discussed tem (see Figure 49A and Figure 49B). In addition, this system is known to play an and project to all parts of the CNS. Recent extremely important role in the control of muscle tone studies indicate that serotonin plays a signifi- (discussed with Figure 49B). One special nucleus CLINICAL ASPECT of this group, the nucleus raphe magnus, Lesions of the cortical input to the reticular formation in located in the upper part of the medulla, plays particular have a very significant impact on muscle tone. This is the physiological basis nervous system at multiple levels. In this model, the same circuit knowing which parts of the limbs and body wall are is activated at a segmental level. We know that mental states and cognitive cussed with Figure 36). There is good evidence that some processes can affect, positively and negatively, the expe- “conscious” perception of pain occurs at the thalamic rience of pain and our reaction to pain. This system apparently func- CLINICAL ASPECT tions in the following way: The neurons of the periaque- In our daily experience with local pain, such as a bump ductal gray can be activated in a number of ways. It is or small cut, the common response is to vigorously rub known that many ascending fibers from the anterolateral and/or shake the limb or the affected region. What we may system and trigeminal system activate neurons in this area be doing is activating the local segmental circuits via the (only the anterolateral fibers are being shown in this illus- touch- and mechano-receptors to decrease the pain sensa- tration), either as collaterals or direct endings of these tion. This area is also known to be rich Some of the current treatments for pain are based upon in opiate receptors, and it seems that neurons of this region the structures and neurotransmitters being discussed here. Experimen- The gate theory underlies the use of transcutaneous stim- tally, one can activate these neurons by direct stimulation ulation, one of the current therapies offered for the relief or by a local injection of morphine. More controversial and certainly less certain is ing cortical fibers (cortico-bulbar) may activate these neu- the postulated mechanism(s) for the use of acupuncture rons (see Figure 46). The axons of some of the neurons of the periaqueduc- Most discussions concerning pain refer to ACUTE tal gray descend and terminate in one of the serotonin- pain, or short-term pain caused by an injury or dental containing raphe nuclei in the upper medulla, the nucleus procedure. CHRONIC pain should be regarded from a raphe magnus. From here, there is a descending, crossed, somewhat different perspective.

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On closer inspection buy 120 mg silvitra erectile dysfunction quad mix, they appear hyperkeratotic and have a small rim of surrounding erythema discount silvitra 120mg visa hypogonadism erectile dysfunction and type 2 diabetes mellitus. He says they are not painful, do not itch, and have been appearing over the course of years. Which of the following statements regarding this patient’s risk of skin cancer is true? The lesions are precursors to melanoma and should be removed B. This patient’s risk of developing a cutaneous malignancy in relation to the lesions is less than 2%, and he should be reassured that they are completely benign C. Treatment of the lesions by methods such as cryotherapy, curettage, or topical chemotherapy has been found to be effective in preventing the progression of such lesions to carcinoma D. Small squamous cell carcinomas arising in the areas described are more likely to metastasize than are more undifferentiated lesions developing in non–sun-exposed areas E. The most important risk factor in the development of these lesions is family history Key Concept/Objective: To know that actinic keratosis is a potential precursor to squamous cell carcinoma of the skin This patient has hyperkeratotic lesions typical of actinic keratosis in sun-exposed areas. Actinic keratosis is seen in areas of chronically sun-damaged skin and is considered a pre- cursor lesion to the development of SCC. The majority of patients with actinic keratosis have multiple lesions, and the risk of SCC in these patients is estimated to be as high as 20%. Thus, it is important that the patient be followed regularly and evaluated by a der- matologist: the removal of these lesions through various techniques can prevent progres- sion to cancer. Small SCCs that arise from actinic keratosis lesions are actually less likely to metastasize than more atypical SCCs, such as those that are poorly differentiated or appear in non–sun-exposed areas or oral or genital mucosa. Sunlight exposure is the most important risk factor for developing actinic keratosis and SCC, although radiation, chem- ical burns, and chronic nonhealing wounds may also predispose to squamous cell cancer. A 59-year-old white woman with rheumatoid arthritis who was treated in the past with methotrexate and courses of steroids presents for evaluation of a mole on her chest. She states that it has been present for years but that, in the past 6 to 8 months, she noticed more irregularity at the borders and an increase in the size of the lesion. Examination reveals an asymmetrical lesion approximately 8 mm in diameter that is variably pigmented from brown to black. You recommend biopsy of the lesion because you are concerned about malignant melanoma. If a primary cutaneous melanoma is confirmed, which of the following factors would be the most important with regard to outcome in this patient? Evolution of the lesion from a dysplastic nevus B. Location of the melanoma Key Concept/Objective: To understand the importance of tumor thickness as a prognostic factor in primary cutaneous melanoma Malignant melanoma is the most aggressive of the primary cutaneous malignancies, and the clinician should have a high index of suspicion when evaluating moles with the char- acteristics of melanoma. The “ABCD” mnemonic is useful for remembering the features of melanoma: asymmetry, border irregularity, color variation, and diameter greater than 6 mm. In this patient, the change in the size of a mole over time also warrants prompt evaluation. The single strongest prognostic factor in melanoma is stage of disease at the time of diagnosis. Staging takes into account tumor size, nodal involvement, and distant metastases. For primary tumors, the most consistent factor predictive of outcome is tumor thickness, as described by the Breslow depth. A 35-year-old white man presents at a walk-in clinic with a complaint of lesions in his mouth and over his trunk. These lesions developed over the past several months. He states that he is homosexual, that he has practiced unsafe sex in the past, and that he has had the same partner for the past 18 months. He denies having previously had any sexually transmitted diseases, but he says he has not had regular health care visits since high school. On examination, you note numer- ous purple-red, oval papules distributed on the trunk and two deep-purple plaques on the soft palate and buccal mucosa. The patient also has several small, firm, nontender, palpable lymph nodes in the poste- rior cervical, axillary, and inguinal chains. Results of routine blood work are unremarkable except for a white blood cell count of 3,000 cells/mm3 and a differential with 5% lymphocytes.

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They may also be phospholipid molecules called phytosomes buy 120 mg silvitra mastercard erectile dysfunction prevalence, which discount 120mg silvitra mastercard erectile dysfunction doctor in jacksonville fl, when attached to the active drug, increase their lipid solubility. A novel percuta- neous delivery system utilizes liposomes, which are specially designed lipid vesicles that are filled with active medication (15,16). Topical anticellulite preparations can be divided into four major groups according to their proposed mechanism of action (Table 1). This includes most of the active ingredients in cellulite treatments. They are included to increase microvascular flow and lymphatic drainage, which is thought to play a role in cellulite pathogenesis. Agents that reduce lipogenesis and promote lipolysis. With the goal of reducing the size and volume of adipocytes, decreased tension on surrounding connective tissue is thought to decrease the clinical appearance of puckering. Agents that restore the normal structure of the dermal and subcutaneous tissue. By thickening the dermis or preventing fat herniation into superficial tissue, the appearance of cellulite may be reduced. Agents that prevent or destroy free-radical formation. It is believed that free radicals modify free fatty acids by peroxidation, contributing to the availability of lipids for cellulite formation. Free radicals may also damage elements of the microcirculation, further assisting cellulite development. The following discussion summarizes the current knowledge of individual and com- bination topical therapies used to reduce cellulite. Table 1 Topical Therapies for Cellulite, Based on Proposed Mechanism of Action Agents that increase microvascular flow Ivy Indian or horse chestnut (Aesculus hippocastanum) Ginkgo biloba Rutin Pentoxyfylline Butcher’s broom (Ruscus aculeatus) Asiatic centella Silicium Chofitol or artichoke (Cynara scolymus) Common ivy (Hedera helix) Ground ivy (Glechoma hederaceae) Sweet clover (Melilotus officinalis) Red grapes (Vitis vinifera) Papaya (Carica papaya) Pineapple (Ananas sativus, Ananas comosus) Agents that reduce lipogenesis and promote lipolysis Methylxanthines (theobromine, caffeine, aminophylline, theophylline) Beta-adrenergic agonists (isoproterenol, adrenaline) Alpha-adrenergic antagonists (yohimbine, piperoxan, phentolamine, dihydroergotamine) Agents that restore the normal structure of the dermal and subcutaneous tissue Retinol (vitamin A) Ascorbic acid (vitamin C) Bladderwrack (Fucus vesiculosus) Agents that prevent or destroy free-radical formation Alpha-tocopherol (vitamin E) Ascorbic acid (vitamin C) Gingko biloba Red grapes (Vitis vinifera) AGENTS THAT INCREASE MICROVASCULAR FLOW Drugs that act on the microcirculation of the skin, include the ivy and Indian chestnut vegetable extracts, which are rich in saponins, Gingko biloba, and rutin, which contain bio- flavonoids. These compounds decrease capillary hyperpermeability and increase venous tone by stimulation of proline hydroxylase and inhibition of prostaglandin E2. These agents also decrease platelet aggregation, thereby inhibiting microthrombus formation. Studies using oscillometry, Duplex ultrasound, hemodynamic methods, and capillaro- scopy have demonstrated that G. This is accomplished by decreasing capillary hyper- permeability and is employed as an active agent in many topical anticellulite formulations. The leaf extracts contain sub- stances such as flavonoids (quercetin, campherol epicathecol derivates, etc. The terpenes, especially ginkgolide B, inhibit the platelet-activating factor. They increment red blood cell deformability, diminish vascular permeability, and improve vas- cular wall tonus. The methylxanthine ‘‘pentoxyfylline’’ improves microcirculatory perfusion through its effect on hematological factors such as erythrocyte shape, platelet aggregation, 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.