Homemade Skin Care Recipes

The Beauty of Food Turning Back The Clock

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Is it true that Botox injections can be used to treat spasticity

Botox can be used to relieve spasticity. However, only neurologists or specialists in physical rehabilitation who are familiar with the special problems that MS patients may encounter should use Botox. Generally, the use of this drug is reserved for patients who have severe spasticity with early contractures in a single muscle group, such as the gastrocnemius, and have failed management with stretching and the drugs previously discussed. Botox is not a panacea for the management of spasticity.

Intrasphincteric Botulinum Toxin Injection

The concept of injecting botulinum toxin into the LES of achalasia patients was suggested by Pankaj Pasricha, as a gastrointestinal fellow at Johns Hopkins. After a series of animal studies confirmed its effect on LES pressure and it did not appear to cause significant histologic injury, we began to study its effect in achalasia patients with gratifying results. These results have been confirmed in controlled trials at Hopkins and elsewhere.

Botulinum Toxin

Although I believe that botulinum toxin should be discussed, the relatively short duration of effect favors the use of other treatment options unless the patient is a poor operative risk or extremely risk adverse. Multiple studies have confirmed that the elderly are substantially more likely to respond to botulinum toxin than are the young. Therefore botulinum toxin seems a better choice for the elderly patient with significant comorbidities. The need for multiple treatments that would presumably continue indefinitely should be adequate explanation to all but the most risk adverse young to seriously consider other options. The original studies of intrasphincteric botulinum toxin used a 20 units mL solution of botulinum toxin type A, injecting 1 mL into each of 4 sites around the circumference of the LES achalasia with a sclerotherapy catheter. Because of the increased pressure in the LES and the dilatation of the esophageal lumen above, the sphincter muscle stands out, making it easy...

Antigen Identification

The antigens recognized by human tumor reactive T cells can be categorized according to their expression profiles in normal tissues and tumors. The differentiation antigens are limited in their expression in the adult primarily to one tissue type and are dominated by the melanocyte differentiation antigens (MDA), which represent gene products that are expressed in melanomas as well as normal skin melanocytes and retinal

Hemifacial Spasm

Speaking, or changes in head position. Typically, the first muscles involved are in the periorbital region, preceded by facial weakness, and within months spreading to ipsilateral facial muscles. These twitches continue in sleep. Blink reflexes are expressed normally. Hemifacial spasms occur when the facial nerve is compressed at the root entry zone, usually by the anterior or posterior inferior cerebellar or vertebral artery. Treatment of choice is botulinum toxin injections, but clonazepam is also prescribed (Sathornsumetee and Stacy in press). Video Segment 29

Facial Acne in Adults

A total of 3,394 women completed the questionnaire of which 3,305 were useable. Prevalence of acne was 41 in adult women. In 17 of the cases, it was 'clinical acne' -with 6.2 inflammatory lesions as a mean - and in 24 'physiological acne' - with 1.3 inflammatory acne lesions as a mean. 97 and 94 , respectively, admitted that they used to scratch or squeeze their 'pimples'. 49 of women with 'clinical acne' had acne sequelae, i.e. scars and or pigmented macules. 34 of women with 'clinical acne' had not experienced acne during their adolescence. A premenstrual flare was recorded in 78 of women with 'clinical acne'. The adult females with acne reported a significantly more oily or mixed type than the non-acne group, sensitive skin was slightly more prevalent in the acne (71 ) and physiologic acne group (68 ) than in the non-acne group (64 ). The sensitivity of the skin to sun was no different among the 3 groups. Smoking, stressful lifestyle and professional occupation were not different...

Clinical Manifestation

The first signs noted in IB are classically those of autonomic blockade. The parasympa-thetic nervous system is more vulnerable to cholinergic blockade by botulinum toxin than the sympathetic nervous system because the parasympathetic pre- and postsynaptic transmissions are affected. In infants with botulism, recognition of the signs and symptoms associated with parasympathetic blockade is important, since these findings precede generalized motor weakness and respiratory decompensation (17,30). The autonomic nervous system dysfunction may include decreased salivation, distention of abdomen and bladder, decreased bowel sounds, fluctuation in blood pressure, heart rate, and skin color.

Introduction to Anaerobes

Gram Stai Bilophila

Propionibacterium acnes Bifidobacterium spp. Spore-forming Clostridium spp. C. perfringens C. septicum C. sordellii C. difficile C. botulinum C. tetani Gram-negative bacilli Bacteroides fragilis group (B. fragilis, Although Clostridium botulinum usually is associated with food poisoning, wound infections caused by this organism are being recognized with increasing frequency. Proteolytic strains of types A and B have been reported from wound infections. Disease caused by C. botulinum usually is an intoxication produced by ingestion of contaminated food (uncooked meat, poorly processed fish, improperly canned vegetables), containing a highly potent neurotoxin. Such food may not necessarily seem spoiled, nor may gas production be evident. The polypeptide neurotoxin is relatively heat labile, and food containing this toxin may be rendered innocuous by exposure to 100 C for 10 minutes. C. botulinum is usually associated with food poisoning (2) botulism is an intoxication caused by...

Preoperative abnormalities

Delay in the relaxation phase of reflexes, dry skin, a husky voice, loss of the outer part of the eyebrows, and weight gain. In severe disease there is lethargy, bradycardia, hypothermia, and respiratory depression. Deposition of a mucinous substance causes thickening of the subcutaneous tissues producing a nonpitting oedema. Myxoedematous infiltration of the vocal cords and tongue can occur. Cardiovascular complications include ischaemic heart disease, bradycardia, pericardial effusion, and cardiac failure (Gomberg-Maitland & Frishman 1998). Neurological complications may involve carpal tunnel syndrome, polyneuritis, myopathy, and cerebellar syndrome.About 70 of patients have paraesthesia or sensory neuropathy. Psychiatric disturbances may predominate.

Treatment of eczema and inflammatory dermatoses

Dry skin tends to be itchy, so advise minimal use of soap. Emollients are used to soften the skin, and the simpler the better. Emulsifying ointment BP is cheap and effective but rather thick. By mixing two tablespoons in a kitchen blender with a pint of water, the result is a creamy mixture that can easily be used in the bath. A useful preparation is equal parts of white soft paraffin and liquid paraffin. Various proprietary bath oils are available and can be applied directly to wet skin. There are many proprietary emollients.

Management And Prognosis

Maintenance of adequate nutrition and hydration is of outmost importance. Parenteral nutrition is usually required because of the likely length of the disease and the undesirability of oral or nasogastric feedings. Adequate nutritional support can minimize weight loss, maintain electrolyte balance, and improve management of arrhythmias. Attention must be paid to skin care, and excretory functions must be monitored closely for urinary retention or serious constipation. Patients must be immunized with tetanus toxoid to prevent further disease. Tracheostomy may be required to prevent laryngospasm, which greatly increases the mortality rate of the disease.

Family Medical History

'In your family - that is, your parents, brothers and sisters - are there any health problems that seem to run through the family ' You may prompt with suggestion such as diabetes, hypertension, and skin problems. This gives you information about predisposition, especially with diabetes and skin problems, and helps with differential diagnosis and may be a contributing factor in the reason for the visit, as for example with impotence or recurrent vaginal candidiasis.

Skin and mouth problems

Many skin problems occur in patients with HIV infection (Box 4.5). These may represent exacerbations of previous skin disease, or a new problem. Identical skin conditions occur in HIV-negative persons. However, in the immunocompromised, these common conditions may be more severe, persistent and difficult to treat. Many minor opportunistic infections (Group IVC2) manifest themselves on the skin and in the mouth. Seborrhoeic dermatitis is frequently seen and usually presents as a red scaly rash affecting the face, scalp and sometimes the whole body. This condition often responds well to 1 hydrocortisone and antifungal cream.

Risk of progression and the value of surrogate markers

Patients who may need close monitoring include individuals whose CD4 count falls below 350 cells mm3, those with a rapidly declining CD4 count, those with a rising viral load and patients who are symptomatic as they may all be candidates for antiretroviral therapy. Patients who present with persistent constitutional symptoms, mouth or skin problems should be considered for antiretroviral therapy irrespective of CD4 count and viral load. These issues are discussed further in the chapters on treatment of infections and antiretroviral agents.

Changes In M0 Tsp1 Expression Levels Influence Tumor Neovascularization

Direct evidence implicating inflammatory M0 and or dermal dendritic cells in psoriatic angiogenesis are not as clear. However, Polverini and Nickoloff (unpublished data) have found that dermal dendritic cells isolated from psoriatic and symptomless skin as well as human monocyte-derived M0 and dendritic cells from normal skin when exposed to conditioned media from psoriatic keratinocytes potently express angiogenic activity, as one might predict. Interestingly, when TSP1 levels in these M0 or dendritic cells were examined and compared to dendritic cells derived from symptom-less or normal skin, TSP1 was virtually undetected. These observations therefore suggest that inflammatory M0 and perhaps dermal dendritic cells can be activated by psoriatic keratinocytes to express angiogenic activity and interfere with their ability to express sufficient levels of TSP1 that would enable them to counterbalance their heightened vasoproliferative activity.

Migration Of Dcs Cells In The Steady State For Tolerance Induction

A closer look into the cytoplasm of veiled cells shows that they are not traveling empty but carry antigens or apoptotic cells derived from the tissue from which they were originating. Many years ago, epidermal LCs were shown to contain melanosomes when emigrating from healthy skin (38), and, more recently, it was shown that this transport of melanosomes decreases in the absence of TGF- 1-dependent LCs (39). Mucosal LCs have also been reported to capture apoptotic epithelial cells in the vagina and cervix (40). In the rat afferent lymph draining from the gut, a subpopulation of DCs contains apoptotic material from their sentinel tissue, which is brought into the mesenteric lymph node (41). Self antigens are transported to the draining lymph node from the pancreas (42) and stomach (43). Also, cells undergoing apoptosis and entering the lymph node through the lymphatics can be captured by lymph node resident DCs for self-antigen presentation (44,45). As no foreign antigens are present...

The Harvesting Process

Clearly, it is important to distinguish between types of onions and their subsequent use for long- or short-term storage when interpreting the results of maturity-date trials. Local practice may vary according to whether optimum yield or a good appearance out of storage is the principal requirement. The timing of harvesting should be decided according to the importance of these considerations relatively early harvesting favours better skin retention while later harvesting maximizes yields.

Supplemental Reading

Annese V, Basciani M, Borrelli O, et al. Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia. Muscle Nerve 1998 21 1540-2. Annese V, Basciani M, Perri F, et al. Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia. Gastroenterol 1996 111 1418-24. Annese V, Bassotti G, Coccia G. A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut 2000 46 597-600. Panaccione R, Gregor JC, Reynolds RP, Preiksaitis HG. Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia a cost minimization analysis. Gastrointest Endosc 1999 50 492-8. Pasricha PJ, Rai R, Ravich WJ, et al. Botulinum toxin for achalasia long-term outcome and predictors of response. Gastroenterol 1996 110 1410-5. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995...

Botulism Syndromes Foodborne Botulism

Foodborne botulism is caused by consumption of foods contaminated with botulinum toxin. C. botulinum multiplies and produces toxin only when the conditions in the food favor its growth. These include an anaerobic milieu, a pH of < 4.5, low salt and sugar, and a temperature of 4 C to 121 C (17). Home-canned foods are a major source of intoxication (1,18,19). Most U.S.A. outbreaks of botulism are associated with food products (e.g., home-canned vegetables), which are not heated adequately before consumption and in which spores produce toxins. In the U.S.A., preserved foods in which the toxin is most often found include string beans, corn, mushrooms, spinach, olives, onions, beets, asparagus, seafood, pork products, and beef (1,20). Improperly smoked or canned fish is the source of type E intoxications. Botulinum spores are common in soil, dust, lakes, and other environmental matter and can contaminate fruits, vegetables, meats, and fish. Honey has been recognized as a potential source...

Microbiology And Toxins

C. botulinum is a gram-positive spore-forming obligate anaerobe, present in the soil worldwide, and has been identified in up to 18.5 of the U.S. soil surveyed (3). C. botulinum is made of four groups of Clostridia (groups I-IV), linked by their ability to produce potent neurotoxins which have identical pharmacologic modes of action. C. botulinum produces seven closely related serological toxins (A-G). Human illness is usually caused by type A, B, or E toxin, and rarely by type Ci, C2, D, F, or G (4-8). Types A and B toxins are highly poisonous proteins resistant to digestion by gastrointestinal enzymes. Unexpressed toxin genes can be found in other clostridial species (and more than one toxin type in a single botulinal strain), confounding molecular diagnostics (9). Each of the four groups of C. botulinum are distinguished by its characteristic biochemical activities. The production of each toxin appears to depend on the presence of a plasmid that encodes the toxin gene. All of the...

Clinical Classification Of Dystonia

The ad hoc committee of the Dystonia Medical Research Foundation also recommended defining five subclasses of distribution of dystonia focal, segmental, generalized, multifocal, and hemidystonia. Focal dystonia is limited to a single body region, segmental to contiguous body regions, generalized to crural involvement (one leg and the trunk or both legs with or without the trunk) plus another body region, multifocal to noncontiguous body regions, and hemidystonia to dystonia affecting ipsilateral limbs. This classification is useful for the clinical monitoring of patients and classification of families for genetics studies. For example, treatment with botulinum toxin may be targeted for focal dystonia because it is usually more practical for a single body area as dose limitations are easily reached if multiple large muscle groups are injected. However, multiple smaller muscle groups can be injected, and therefore segmental cranio-cervical dystonia may also respond, or botulinum toxin...

Therapeutic Alternatives and Developping Treatments in Refractory Urge Incontinence and Idiopathic Bladder Overactivity

Conservative therapies such as pelvic floor exercises, bladder retraining, electrical stimulation of the pelvic floor and pharmacotherapy involving anticholinergics, antispasmodics and tricyclic antidepressants are primary discussed. The use of pelvic floor muscle training with or without biofeedback for overactive bladder is suggested to inhibit detrusor muscle contraction by voluntary contraction of the pelvic floor at the same time, and to prevent sudden falls in urethral pressure by change in pelvic floor muscle morphology, position and neuromuscular function 17 . Some promising results have been reported, and these treatments are widely used, but there is still a need for high quality randomized trials on the effect of pelvic floor exercises on the inhibition of detrusor contraction. Detrusor over-activity current pharmacological treatment involve use of muscarinic receptor antagonists, but their therapeutic activity is limited by side effects resulting in the non continuance of...

Multimodal neurosurgical strategies for the management of dystonias

The most common type of task-specific focal hand dystonia is writer's cramp and musician's cramp. Such condition is very miserable, especially when the symptom is related with the patient's profession. As there have been some case reports on thalamotomy for writer's cramp, we started ventrooral thalamotomy for task-specific focal hand dystonia about five years ago 7 . This was because botulinum toxin injection is not approved in Japan for symptoms other than neck and face dystonias. The ventrooral nucleus of the thalamus receives inputs from GPi and forms part of the thalamo-cortical-basal ganglia loop. Task-specific focal hand dystonia is regarded as the result of oscillation of this cerebral circuit, and making a small lesion in this loop to de-sensitize the loop is the theoretical background of this treatment. So far we have treated 22 patients with writer's cramp and four with musician's cramp. Immediately after the operation, the effect is generally dramatic, but the problem is...

Infant Botulism See Chapter

Infant botulism results from absorption of heat-labile neurotoxin toxin produced in situ by C. botulinum that can colonize the intestines of infants younger than one year of age (39). It is an age-limited neuromuscular disease that is distinct from classic botulism, in that the toxin is elaborated by the organism in the infant's intestinal lumen and is then absorbed. administration of human botulinum immunoglobulin in severe cases (41).

Clinical Signs and Diagnosis

Because wound botulism symptoms result from infection with C. botulinum organisms and subsequent in vivo production of toxin, the incubation period is longer (4-18 days) than for foodborne illness (six hours to eight days) (10,21,22). The clinical manifestations are similar to those of foodborne botulism except for the lack of early gastrointestinal symptoms. Early symptoms can include appearance of lethargy owing to muscle weakness, ptosis, blurred or double vision, dry, sore throat (21), and a subsequent descending weakness of the respiratory muscles. Fever, which usually is absent in foodborne botulism, may be present in wound botulism. The diagnosis of wound botulism is suggested by clinical findings and the presence of an apparent wound source. Diagnostic methods are the same as for other forms of botulism and also include unroofing of lesions to obtain specimens for culture and toxin assay. Confirmation of the diagnosis is made by demonstration of toxin in serum or by isolation...

Stump Preparation for a Prosthesis

Stump Crutch

Effective means of conditioning lower limb stumps and also of encouraging the patient psychologically. Thomas and Haddan, however, believed this was unnecessary in civilian practice, for a permanent limb could be fitted within a few weeks, and shrinkage countered by adding stump socks, and making a new socket if required, only needed for some 25 of amputees in the United States. Stump hygiene was vital by daily washing and change of socks, by exposure to fresh air as much as possible, by reducing friction and by using talcum or lanolin for dry skin.43

New Developments and Future Trends

Leukotrienes Inflammatory Mediators

Additional results have shown that the sebaceous gland expresses a number of different cytokines at steady state, without the influence of any external factors. Antilla et al. 104 showed that IL-1 is present in normal sebaceous glands and Boehm et al. 105 used in situ hybridization techniques to show that messenger RNA (mRNA) for IL-1a, IL-1P and tumor necrosis factor-a is present at multiple sites in normal skin including the sebaceous glands. Thus, while the presence of bacteria, most notably P. acnes, may stimulate upregulation of cytokine expression in sebaceous glands 106 , pro-inflammatory cytokines are expressed in these tissues in the absence of defined external influences.

Outlet Dysfunction Constipation

Botulinum toxin injections into the anal sphincters for the treatment of dyssynergic defecation has been reported in small uncontrolled studies. We are not convinced that there is sufficient evidence to use botulinum toxin for this disorder nor do we recommend myotomy for the pub-orectalis muscle because of a high risk of incontinence.

Lumbar and sacral radiculopathy

Atrophy Paraspinal Muscles Image

Motor involvement following sacral herpes S 1 on the right side. The vesicles can no longer be seen. A Right sided gluteal weakness with loss of muscle definition on the right compared to the intact left side. B Discrete dry skin changes over the right half. C Note the skin over the plantar right foot, which appears to be wrinkled compared to left side (atrophy of the small foot muscles)

Adult Intestinal Toxemia Botulism

Adult intestinal toxemia botulism occurs rarely and sporadically, and it results from the absorption of toxin produced in situ by botulinum toxin-producing Clostridia that colonizes the intestine. Generally, patients have an anatomical or functional bowel abnormality or are using antimicrobials, which may select fastidious Clostridium species from the normal bowel flora (30,35,36). The symptoms may be protracted and relapsed even after treatment with antitoxin because of the ongoing intraluminal production of toxin. Typically, there is no known food or wound source and prolonged excretion of organisms and toxin is present in the stool.

Surgical Stump Management

Approximation Stump

Probably this solution was successful because most of his amputees were young men with good skin and tissue circulation older patients, especially with vascular deficiency, would require great care to prevent skin damage by adhesive plaster extension. In 1872, Bryant had recommended traction for any stump showing signs of wound retraction, applying weight indirectly to a perforated zinc splint which was bound firmly to the bandaged stump.9

The Quest For Immortality

But so far, all attempts at physical rejuvenation have failed. Many such attempts date back to the turn of the early 1900s and involved the use of concoctions, potions, and even radioactive cocktails, often with disastrous results. One such concoction, popular in the 1920s, was Tho-Radia, a skin cream containing thorium and radium, two radioisotopes discovered by the great French physicist Marie Curie. The radioactive material was supposed to have an antiaging effect on the skin, but their use was abandoned when Curie and other scientists working with radioisotopes began having serious medical problems. Madame Curie developed cataracts, kidney failure, and a fatal leukemia, all from overexposure to radioactive materials.

Umbilical Artery In Adults

Alcohol Absorption Pics

Percutaneous alcohol absorption with resultant erythema and burns to the buttocks of a premature infant. During placement of an umbilical arterial catheter, alcohol or iodine may track down the sides of the abdomen and soak the underlying sheet. Evaporation is restricted from the skin in contact with the underlying sheet and this may result in irritation, erythema, and severe burns, especially in a premature infant with very sensitive skin. Figure 7.9. Percutaneous alcohol absorption with resultant erythema and burns to the buttocks of a premature infant. During placement of an umbilical arterial catheter, alcohol or iodine may track down the sides of the abdomen and soak the underlying sheet. Evaporation is restricted from the skin in contact with the underlying sheet and this may result in irritation, erythema, and severe burns, especially in a premature infant with very sensitive skin.

Incisional biopsy and punch biopsy

Foot Punch Biopsy

This is suitable for larger lesions and is taken across the margin of the lesion in the form of an elipse. It is essential to include deeper dermis, as the significant changes in, for example, granuloma or lymphoid infiltrate may not be near the surface. An adequate amount of normal tissue should be included, so this could be compared with the pathological area and this also means there is enough normal skin to suture the incision together.

Fraunhofer solar spectrum

The assessment of impairments of the musculoskel-etal system by the doctors and physiotherapists examines the aspects Is the muscle spastic to passive extension Does the muscle show increased stiffness when stretched Does the muscle have fixed shortening Careful treatment depends on clinical patterns of motor dysfunction in order to identify the best method of treating functional problems as there are the flexed hip, scissoring thighs, stiff knees, equinovarus foot, bent elbow, pronated forearm, bent wrist, clenched fist, thumb-in-palm deformity. In addition, pharmacological reduction of spasticity can be achieved by local injections of phenol for peripheral nerve blocks and today by the local application of Botulinum toxin, which inhibits the release of actetylcholine causing flaccid paralysis. Both techniques are helpful adjuncts for standard use of casting 15, 16 . Sometimes long-bone and pelvic fractures that are stabilized with the aid of a fixateur externe after polytrauma might...

Preoperative management

Immediate management should also include attention to palliation and skin care, nutrition, physiotherapy, rehabilitation and overall patient morale. Surgical fistula patients are usually previously healthy individuals who entered hospital for what was expected to be a routine procedure, and end up with symptoms infinitely worse than their initial complaint. Obstetric fistula patients in the developing world are social outcasts. Whatever the cause, these women are invariably devastated by their situation. It is vital that they understand the nature of the problem, why it has arisen, and the plan for management at all stages. Confident but realistic counselling by the surgeon is essential and the involvement of nursing staff or counsellors with experience of fistula patients is also highly desirable. The support given by previously treated sufferers can also be of immense value in maintaining patient morale, especially where a delay prior to definitive treatment is required.

Picture Of Skin Dimpling

A pigmented skin dimple over the left shoulder. Normal skin dimples in general tend to occur in areas where the skin is relatively tightly bound to the underlying bony prominences. Figure 1.61. A pigmented skin dimple over the left shoulder. Normal skin dimples in general tend to occur in areas where the skin is relatively tightly bound to the underlying bony prominences.

Other Dermatologic Problems

Infants With Abnormal Big Head

The typical facies of hypohidrotic (anhidrotic) ectodermal dysplasia is seen in this infant. Note the alopecia, absent eyebrows and eyelashes, square forehead with frontal bossing, hyperpigmented wrinkles around the eyes, flattened nasal bridge, and large conspicuous nostrils. There are wide cheek bones with depressed cheeks, thick everted lips, a prominent chin, and the ears may be small and pointed. These infants have a thin dry skin, decreased sweating, decreased tearing, and abnormal dentition. The nails are defective in a large percentage of these patients in that they may be thin, brittle, or ridged. If the absence of the sweat glands is generalized, they may have recurrent fever in high environmental temperatures.

Treatment of Dystonia

High-dose anticholinergic therapy was found to be effective in ameliorating dystonia, particularly in younger patients. Other agents such as baclofen, benzodiazepines, carbamazepine, and tetrabenazine are reported to benefit some dystonic patients (Adler and Kumar 2000 Jankovic and Orman 1988). In addition, all childhood onset dystonia patients deserve a trial of levodopa. Intramuscular injection of botulinum toxin is the most effective treatment for focal dystonia, and may be used in a limited setting for patients with generalized dystonia. Intrathecal baclofen provides symptomatic benefit only for some patients who fail on oral medications (Walker et al. 2000). DBS at the internal segment of globus pallidus is effective in primary dys-tonia (particularly DYT1 dystonia), the myoclonus-dystonia syndrome, and complex cervical dystonia (Vitek et al. 2004).

Sebaceous Glands in Acne

Pathogenesis Acne

It is generally accepted that sebaceous glands were not innervated and the peripheral nervous system has no effect on the sebaceous biology. Indeed, nerve fibers, as documented immunohistochemically using the general neuronal marker PGP 9.5, were rarely observed around the sebaceous glands in normal facial skin. In contrast, facial skin from acne patients shows numerous fine nerve fibers not only around but also within sebaceous acini 19 . Numerous nerve endings were also observed in close apposition to the sebaceous glands ultrastructurally. Such increase in the number of nerve fibers, some of which are even invading into sebaceous acini, may result from increased expression of NGF on the sebaceous glands of acne-prone facial skin since NGF is essential for the survival, development, differentiation and function of peripheral sympathetic and sensory neurons, and acts as a neurotrophic molecule stimulating the sprouting of nerve fibers also in the skin 20 . Immunohistochemical study...

Convex Triangular Foot Hallux Valgus And Quintus Varus

Foot Varus

The diabetes had been adequately controlled but the patient was already exhibiting signs of diabetic complications, such as background retinopathy and neuropathy. On examination, she had a right convex triangular foot, with an ulcer under the head of the fifth metatarsal head following callus formation at this site (Figure 3.15). She had symptomatic diabetic neuropathy, exemplified by a burning sensation in the feet, which was especially exacerbated at night peripheral pulses were palpable and the ankle brachial index was 1.0 bilaterally. Small muscle atrophy of the feet was noted, as well as dry skin and loss of feeling of a 5.07 monofilament vibration perception threshold was 30 V.

Necrosis and renal impairment

Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic. Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic. Necrosis can occur in diabetic renal patients with palpable pulses in the absence of severe peripheral arterial disease and in the absence of infection. An apparently small and trivial trauma such as a small split in dry skin (Fig. 6.9) or a tight nail sulcus will frequently lead to necrosis which then spreads (Fig. 6.10). Necrotic lesions often become rapidly infected in diabetic patients with renal failure.

Feckless patient with endstage renal failure

Necrosis Toes

Causes of trauma included blisters from ill-fitting shoes, picking at dry skin, pulling off pieces of nail and being 'trodden on by a baby'. In the last episode she stubbed her toe while walking barefoot, did not report the injury and presented late to the renal unit with spreading cellulitis, wet necrosis and

The significance of skin disease

The skin is not only the largest organ of the body, it also forms a living biological barrier and is the aspect of ourselves we present to the world. It is therefore not surprising that there is great interest in skin care, with the associated vast cosmetic industry. The impairment of the normal functions of the skin can lead to acute and chronic illness with considerable disability and sometimes a need for hospital treatment.

Predisposing Conditions And Pathophysiology

IB results from the ingestion of C. botulinum spores. Even though honey is a known source, in about 85 of patients the source is unknown. BI cases occur from six days to 12 months of age and not later. Information derived from a mouse model and clinical cases suggest that transient absence of competitive microbial intestinal flora and or alteration in motility or pH enables outgrowth of vegetative forms from ingested spores. Recently, weaned infants that have been exclusively breast-fed and, when changes of intestinal flora occurs, are at risk for IB. Replicating C. botulinum, and occasionally C. baratii and C. butyricum, produce distinctive botulinal neurotoxins (types A-G) of high potency. After systemic absorption, toxin binds to Colonization is believed to occur because normal bowel flora that could compete with C. botulinum have not been fully established. Breastfeeding is a risk factor for IB in all studies (13,16-21). This may be the case because it truly predispose to illness...

Microbiology

C. botulinum is a gram-positive spore-forming obligate anaerobe that is present in the soil worldwide and may spread by dust. It is composed of four groups of clostridia (groups I-IV), linked by their ability to produce potent neurotoxins which have identical pharmacologic modes of action. Botulinal toxin is the most potent neurotoxin known (2). The toxin does not appear to cross the blood-brain barrier and it exerts its toxicity through affecting the transmission at all peripheral cholinergic junctions. It interferes with the normal release of acetylcholine from nerve terminals in response to depolarization (3). The toxin binds irreversibly, and recovery of function depends on ultra-terminal sprouting of the nerve to form new motor end plates.

Epidemiology

IB is a restricted age-range disease. Ninety-five percent of all recognized cases have occurred in patients between six weeks and six months of age. The disease affects equally all major racial and ethnic groups and both sexes. More than 1500 cases of IB have been confirmed in the U.S.A. since it was recognized in 1976. IB is the most common form of botulism, with about 80 to 100 (median of 71) cases reported annually in the United States (4-7). Almost all cases of IB are caused by proteolytic C. botulinum group I strains that produce either type A or B (or Bf) neurotoxin. Type E neurotoxin-producing Clostridium butyricum was recovered from infants (7). Clostridium baratii strains can also produce type F botulinal toxin, and has also been recovered from infants with botulism (8-10). IB has been reported from all inhabited continents except Africa. In the U.S.A., differences in the regional soil distribution of C. botulinum exist. C. botulinum spores that produce toxin B are mainly...

Diagnosis

EMG can provide rapid bedside substantiation of the clinical diagnosis of IB. If the BSAP pattern is present (34,36), then many of the other diagnostic tests and procedures to which patients are subjected may be deferred while laboratory examination of fecal specimens for C. botulinum toxin and organisms proceeds. The diagnosis of IB is established unequivocally only when C. botulinum organisms are identified in a patient's feces, as C. botulinum is not part of the normal resident intestinal microflora of infants or adults (34,40,41). Confirmation of the clinical diagnosis requires the demonstration of botulinus toxin or C. botulinum in feces of the infant. The mouse neutralization assay is used to test for the presence of toxin in feces or the serum. Therefore, serum, and fecal specimens should be collected as soon as the diagnosis of botulism is suspected. It is sometimes possible to identify small amount of the toxin in serum if the specimen is collected early in the illness (42).

Management

Seriously ill patients require hospitalization for up to two months. Careful maintenance of adequate ventilation and caloric intake is of particular importance. The need for respiratory assistance, if any, generally occurs during the first week of hospitalization. Parenteral antibiotic therapy in an attempt to eradicate C. botulinum toxin and organisms from the intestinal tract usually is unsuccessful and should be reserved for cases with proved or suspected sepsis caused by other organisms. Antibiotics are not recommended for IB and will not affect the course of illness or recovery. When penicillin or its derivatives have been used, neither oral nor parenteral administration succeeded in producing discernible clinical benefit or in eradicating either C. botulinum organisms or botulinus toxin from the intestine (17,34). Effective antibiotics may increase the pool of toxin in the bowel available for absorption as it is liberated following bacterial cell death. Another argument against...

Prevention

Since C. botulinum spores are heat resistant and may survive boiling for several hours, home cooking of foods may not destroy C. botulinum spores. Washing and peeling raw foods before cooking may substantially reduce the number of spores, if present. The single food fed to patients that has been identified as a source of C. botulinum spores, but not of preformed botulinum toxin, is honey (34,40,48). Furthermore, honey exposure has been implicated as a significant risk factor for type B IB (48). A survey of honey samples not associated with cases of IB found that 7.5 contained C. botulinum, toxin-producing type A or type B or both. The honeys that contained C. botulinum originated in various parts of the U.S.A. (40). Since honey is not essential for infant nutrition, it is recommended that honey not be fed to infants less than one-year old. Previously corn syrup contained botulinum spores, but changes in corn syrup production have apparently eliminated this problem. The full extent of...

The curing process

During curing, the thin outer layers of the bulb are dried to form one or more complete dry skins, which act as a barrier to water loss and microbial infection. Ideally, the dirty outer skins can be removed after storage to show a clean, intact, inner dry skin before retail sale. Even for fresh-market onions, at least one complete skin should be present.

Ovarian Ablation

For premenopausal women with receptor-positive disease, medical or surgical castration is also an effective approach to hormonal therapy. The endocrinologic effect of castration is achieved by two analogs of gonadotropin-releasing hormone, goserelin and leuprolide, which suppress follicle-stimulating hormone and luteinizing hormone, and thus estrogen production by the ovary.62,63 Either agent will achieve the same benefit as oophorectomy, that is, a 45 percent likelihood of disease regression or stabilization, but require parenteral administration on a monthly or tri-monthly basis. Side effects are limited to pain at the injection site and menopausal symptoms such as hot flashes, mood swings, and dry skin. Once disease progresses after either medical or surgical castration, the alternate approach has little chance of benefit. Obviously, castration by either technique can only be of benefit to pre-menopausal patients, where the ovary is the primary site of estrogen production.

Osteomyelitis

On examination, she had findings of severe neuropathy (no feeling of light touch, pain, temperature, vibration or a 5.08 monofilament Achilles tendon reflexes were absent the vibration perception threshold was > 50 V in both feet). Peripheral pulses were weak and the ankle brachial index was 0.7. Dry skin and nail dystrophies were present. A superficial ulcer with a sloughy base was seen on the dorsum of

Surgical treatment

Freezing warts with liquid nitrogen is a rapid method of treatment. It is contraindicated in small children, since it is frequently associated with intense pain secondary to oedema under the nail bed. Application of a surface anaesthetic cream 1-2 hours prior to therapy does not help to reduce pain in the periungual region. Hyperkeratotic warts should be pared off before treatment to permit freezing of the deeper portions of the wart. Freezing takes 10-15 seconds using cryogen spray. A 1 mm halo ring should form in the normal skin surrounding the wart. Cryosurgery should be used with caution for warts on the proximal nail fold, since nail matrix damage is a common complication, with leukonychia, Beau's lines and onychomadesis. Irreversible matrix destruction with nail atrophy has been reported after overzealous cryosurgery.

Figure 545

These usually disappear before the patient presents to the doctor. Confluent eczematoid changes cover the skin immediately adjacent to the distal edge of the nail. The affected area is pink or of normal skin colour and densely studded with fine scales there is a clear margin between the normal and affected areas. The skin changes may extend to the dorsal aspect of the finger or toe, but usually only the finger tip is affected. The most striking and characteristic change is the hyperkeratosis beneath the nail tip. The nail plate is lifted up, deformed and often thickened. Commonly the deformity produced is asymmetrical and limited to one corner of the distal edge, or at least more pronounced at the corners of the nail. Pitting occurs in some cases rarely, transverse ridging of the nail plate is present. In most cases the condition resolves within a few months, but in some cases it may persist for many years, even into adult life.

Abstract

There is ample clinical evidence suggesting that the nervous system such as emotional stress can influence the course of acne. We examined possible participation of cutaneous neurogenic factors including neuropeptides, neuropeptide-degrading enzymes and neurotrophic factors, in association with inflammation in the pathogenesis of acne. Immunohistochemical studies revealed that substance P (SP)-immunoreactive nerve fibers were in close apposition to the sebaceous glands, and that neutral endopeptidase (NEP) was expressed in the germina-tive cells of the sebaceous glands in the skin from acne patients. Nerve growth factor showed immunoreactivity only within the germinative cells. In addition, an increase in the number of mast cells and a strong expression of endothelial leukocyte adhesion molecule-1 on the postcapillary venules were observed in adjacent areas to the sebaceous glands. In vitro, the levels and the expression of stem cell factor by fibroblasts were upregulated by SP. When...

Botul sm

Botulism is a rare paralytic disease caused by a neurotoxin produced from the spore-forming bacterium Clostridium botulinum and in rare cases, Clostridium butyricum and Clostridium baratii. Botulism in humans is usually caused by toxin types A, B, and E. Since 1973, a median of 24 cases of foodborne botulism, 3 cases of wound botulism, and 71 cases of infant botulism have been reported annually to the Centers for Disease Control and Prevention (CDC) (1,2). Botulism has four naturally occurring syndromes foodborne, wound, infant botulism, and adult intestinal toxemia. Inhalational botulism could result from aerosolization of botulinum toxin, and iatrogenic botulism can result from injection of toxin. All of these produce the same clinical syndrome of symmetrical cranial nerve palsies followed by descending, symmetric flaccid paralysis of voluntary muscles, which may progress to respiratory compromise and death. The weaponization of botulinum toxin is of great concern.

Evolving Therapies

Some reports have shown that diabetic patients with gas-troparesis have abnormally high pyloric sphincter pressures. This has lead to the concept of pyloric spasm and the idea that therapies aimed at relaxing the pyloric sphincter could improve gastric emptying. The use of sildenafil and local botulinum toxin A injections have been proposed to address this particular pathophysiology. Preliminary reports suggest that 100 to 200 Units of botulinum toxin injected directly into the pylorus endoscopically is effective in temporarily relieving symptoms in idiopathic and diabetic gastroparesis, although further study is needed (Ezzeddine et al, 2002). It would seem best suited to the setting of an accidental vagal nerve injury accompanying fundoplication or esophageal surgery. Here it would simulate the effects of a pyloroplasty without the necessity for surgery. Since repeated administration will be required, formulation and administration issues may preclude its use as a first line...

Botulism

Functional anatomy Botulinum toxin is produced by gram-positive anaerobic bacilli that proliferate - Infant botulism occurs in children younger than 6 months. C. Botulinum spores are ingested and proliferate in the gastrointestinal tract. Ingestion of raw honey may be the cause. Symptoms include weak crying, feeding difficulties, and weak limb muscles. Parasympathetic blockade may be - Inadvertent botulism results from patients treated with botulinum toxin that has effects at sites distant from the site of treatment. Prolonged jitter and increased blocking can be observed in SFEMG.

FollowUp

Should the initial botulinum treatment be unsuccessful or result in a response of limited duration, I will generally perform a second injection of the same dose of toxin before deciding to move onto an alternative approach. We have found that if the second injection fails, additional attempts are fruitless. Should the first dilatation fail, I will perform a second, this time with a 35 mm achalasia balloon. I feel that dilatation with larger balloons is associated with a significant escalation in the risk of perforation, and I only use the available 40 mm balloon under unusual circumstances and usually only if the patient wants to avoid other options at all costs. After treatment, I primarily follow the patient's clinical response, using objective studies to provide new baselines and to correlate with symptoms. Of the available tests, the post-treatment LES pressure appears to be the best indicator oflong term response after both botulinum toxin injection and dilatation. However,...

Neurologic Disease

Several problems are more frequently encountered in patients with significant neurologic disease. The presence of dysphagia necessitates precautions against aspiration, and measures to enhance swallowing, or the use of enteral feedings sometimes must be considered. Dystonia can lead to great discomfort or contractures, and use of muscle relaxants or direct injection of muscle groups with botulinum toxin can give relief. Dysarthria can inhibit communication, and assistance from a speech therapist may be helpful in improving certain aspects of speech. The use of a signboard or electronic communication devices has helped for some individuals. Physical and occupational therapy may help maintain strength and assist with problems with coordination. Tremor can at times be disabling, and muscle relaxants or other therapies may be sought. Some patients may have the severe bradykinesia and gait disturbance of parkinson-ism. In these individuals, consultation with a neurologist

Secondary Survey

Burns are classified as being superficial, partial thickness, or full thickness. The first causes injury only to the epidermis and clinically the skin appears red with no blister formation. Partial-thickness burns cause some damage to the dermis blistering is usually seen and the skin is pink or mottled. Deeper (full-thickness) burns damage both the epidermis and dermis, and may cause injury to deeper structures as well. The skin looks white or charred, and is painless and leathery to touch.

Neuropathic Ulcer

Proximal Fifth Metatarsal

A non-infected neuropathic ulcer was noted under her left third, fourth and fifth metatarsal heads. Its dimensions were 3.5 x 4 x 0.4 cm, and it was surrounded by callus. A smaller neuropathic ulcer was also observed under her midsole (Figure 5.10). Claw toe deformity of her lesser toes, dry skin and desquamation of the tip of her third toe were also present. Under her Figure 5.10 Neuropathic ulcers under prominent metatarsal heads and on the midsole. Claw toes and dry skin are also apparent Figure 5.10 Neuropathic ulcers under prominent metatarsal heads and on the midsole. Claw toes and dry skin are also apparent

Comedonal Types

Submarine Comedones

Biopsy sections of normal-looking skin in an acne-prone individual with comedonal acne will frequently (28 ) show histological features of microcomedones. Biopsies of papules taken at up to 72 h of development will reveal a microcomedone in 52 of subjects, a whitehead in 22 and a blackhead in 10 22 , confirming even further the practical need to apply topical therapies to apparently non-involved skin.

Histopathology

Saprolegnia lesions in channel catfish initially occur at the site of injury, containing a central zone of either necrotic skin, with fungal mycelia throughout the lesion, or, in more severe lesions, a necrotic core of sloughed tissue, which leaves a crater-shaped cavity (Xu and Rogers, 1991). In some lesions, the epidermis has been reported as completely sloughed, leaving the dermis exposed (Xu and Rogers, 1991 Bly et al., 1992). Adjacent tissue becomes infected following the spread of hyphae on the skin surface, and mucus cells present in normal skin are absent in the infected skin.

Local treatment

Lupus Erythematosus Treatment

Dithranol, obtained originally from the Goa tree in south India, is now made synthetically. It can easily irritate or burn the skin, so it has to be used carefully and should be kept from contact with normal skin as far as possible. For hospital treatment pastes are used and the lesions surrounded by petroleum jelly to protect the normal skin. Dithranol creams can be used at home they are applied for 30 minutes and then washed off. A low concentration (0-1 ) is used initially and gradually increased to 1 or 2 as necessary. All dithranol preparations are irritants and produce a purple-brown staining that clears in time. If used in the scalp dithranol stains red or fair hair purple. Emollients soften dry skin and relieve itching. They are a useful adjunct to tar or dithranol.

Anal Fissure

The main goal of treatment is breaking the cycle of hard stool, pain, and reflex spasm. This objective can usually be achieved by increasing dietary fiber using fiber supplements, adequate liquid intake, and possibly stool softeners. Warm baths and topical anesthetics are helpful in providing symptomatic relief. The great majority of patients with acute anal fissure will respond to medical treatment. For patients with chronic anal fissure, several recently developed nonsurgical methods, including nitric oxide and botulinum toxin, are available (Utzig et al, 2003). Calcium channel blockers and a-adrenoceptor antagonists are still at the developmental stage. Nitric oxide ointment is used in a concentration of 0.2 , usually tolerable by patients, and applied in the anal canal 2 or 3 times daily for 8 weeks. Transient headache is a major side effect of this treatment, more commonly seen at higher concentrations of the compound. Botulinum toxin injection is indicated for patients who are...

Crosssection

Nucleus Ambiguus Wallenberg Sendromu

Interruption of the descending autonomic fibers gives rise to a clinical condition called Horner's syndrome. In this syndrome, there is loss of the autonomic sympathetic supply to one side of the face, ipsilaterally. This leads to ptosis (drooping of the upper eyelid), a dry skin, and constriction of the pupil. The pupillary change is due to the competing influences of the parasympathetic fibers, which are still intact. Other lesions elsewhere that interrupt the sympathetic fibers in their long course can also give rise to Horner's syndrome.

Phlegmon

Callus Formation

On examination, the patient had fever, severe diabetic neuropathy, and bounding pedal pulses. He had hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin. Callus formation superimposed on a neuropathic ulcer over his third metatarsal head was present a callus was also noted over his fifth metatarsal head. A superficial, painless, Figure 8.21 Superficial infected ulcer with purulent discharge under Lisfranc's joint. Callus formation is superimposed on neuropathic ulcer over the third meta-tarsal head with callus formation over the fifth metatarsal head. Hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin can be seen Figure 8.21 Superficial infected ulcer with purulent discharge under Lisfranc's joint. Callus formation is superimposed on neuropathic ulcer over the third meta-tarsal head with callus formation over the fifth metatarsal head. Hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin...

Infantile Acne

Infantile acne must be differentiated from acneiform eruptions due to topical skin care products (greasy oint-memts, creams, pomades, oils) applied by the parents (pomade acne) due to steroids (topical, oral, inhaled) and from skin contact, ingestion or inhalation of aromatic hydrocarbons with chlorine groups (chloracne) 1, 20 . Perioral dermatitis can mimic an IA, papules and pustules are present mainly periorally (95 ) and occasionally at the periocular area (44 ). It can be associated to kerato-conjunctivitis and vulvar lesions in female patients and usually occurs due to steroids. A family history is present in 20 of cases 21 .

Pes Cavus

On examination, peripheral pulses were bounding. She had severe peripheral neuropathy (no sensation of pain, light touch, temperature, vibration or 5.07 monofilaments) and dry skin. A high plantar arch due to pes cavus was noted, which was more apparent in the standing position. Mild hallux valgus, clawing of the toes, and callus formation over the inner aspect of the first metatarsal heads as well as at the tip of the second toe and the second metatarsal head bilaterally were observed (Figure 3.4). The patient had the callus removed, and the nails cut and she was educated in foot care. Suitable shoes and insoles were prescribed and she was advised to attend the foot clinic on a monthly basis for chiropody treatment.

Rectal pain

Anal tags are normal skin variation, and though they do not cause any symptoms or require treatment, sometimes they may be a clue to an underlying condition. As has earlier been stated, tags can be associated with Crohn's disease these tags are usually thick with a purplish appearance. Anal tags can occur as the result of a thrombosed external pile or may form the marked end to a chronic anal fissure.

Flutamide

Flutamide does not interfere with ovulation and is generally well tolerated. The only common complaint of patients given flutamide is dry skin, attributable to reduced sebum production. Liver toxicity is an uncommon, but potentially severe, risk with this drug (24). On the whole, from several points of view, flutamide is probably the best available antiandrogen drug. However, this drug should be used with caution for the treatment of hirsutism, and in these cases serum transaminases should be carefully monitored.

DNAR Orders

The attending physician should clarify both the DNAR order and plans for future care with nurses, consultants, house staff, and the patient or surrogate and offer an opportunity for discussion and resolution of conflicts. Basic nursing and comfort care (ie, oral hygiene, skin care, patient positioning, and measures to relieve pain and symptoms) must always be continued. DNAR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately and communicated to staff.

Think Clean and Green to Flawless Skin

Think Clean and Green to Flawless Skin

Lets accept the fact: many of us are skin conscious. As much as possible, we wanted to have a fresh, good looking skin. However, many of us failed to recognize that simple steps are the best ways to attain it.

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