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Scalp and Face Pruritus History It would be unusual for pruritus in the head and neck to indicate anything except a skin condition/disease or infestation purchase 5 mg propecia hair loss hypertension medication. If the patient is a school-age child propecia 1 mg mastercard hair loss young men, pediculosis is an obvi- ous choice and the child’s friends and school administrators should be questioned about recent outbreaks. You should ask about sun exposure and blistering sunburns. A history of other skin cancers in the patient or family is important to determine. Physical Examination The physical exam includes careful inspection of the head and scalp for nits or actual lice. Nits are fixed to the hair shaft and are grayish-white in appearance. Unlike the flakiness of seborrhea, nits cannot be easily dislodged. The skin of the head and face should be inspected for lesions, color changes, new or changing moles, crusting, scaling, ulceration, or bleeding, which might be indicative of cancer or psoriasis. Pediculosis (Head Lice) See Pediatric Patients (Chapter 17). Tinea Capitus Tinea capitus is a fungal infection of the scalp seen mainly in children. It is characterized by scaly patches, sometimes annular, and often accompanied by hair loss in the area. Head, Face, and Neck 43 Neck Fullness/Mass or Pain History Start with a thorough history, including a past medical history for cancer or exposure to environmental toxins. Ask about frequent infections; allergies; chronic ear, nose, and throat problems; or surgeries. Ask about living arrangements because close quarters, such as class- rooms and college dormitories, can predispose the patient to a variety of infections. Inquire about family history, especially thyroid disease. The symptoms will vary depending on the underlying cause. In thyroid disease, patients may describe a feeling of having something in their throat. The complaint is more likely to be one of fullness rather than of pain or dysphagia. The history should inquire about signs and symptoms of hyper- or hypothyroidism, such as weight loss or gain, nervousness or fatigue, diarrhea or constipation, intolerance to heat or cold, insomnia or lethargy, men- strual irregularities, and skin or hair changes. Laboratory studies and thyroid scanning can diagnose most problems. Lymphadenopathy has numerous causes but can generally be placed into two categories: infection or malignancy. Infection often presents with fever, sore throat, runny nose, cough, and malaise. A history of an upper respiratory infection is common. Symptoms of malignancies are more likely to be fatigue, weakness, anorexia, weight loss, fever, night sweats, bleeding, and easy bruisability. A history of tobacco and/or EtOH abuse may be present in neoplasms of the head and neck. Physical Examination The physical exam includes palpation of the thyroid for enlargement, asymmetry, or nod- ules. Look for periorbital edema, which may be present in hypothyroidism. Check the vital signs for hyper- or hypotension, tachy- or bradycardia, and fever or subnormal temperature. Abnormalities in any of these areas would indicate the need for further thyroid studies, including thyroid-stimulating hormone (TSH), T3, T4, and possi- bly a thyroid scan. A complete examination of the mouth, throat, nose, ears, and eyes should be performed as you look for infection.

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These techniques are very sensitive and are used to evaluate the outermost surfaces of alloys discount 1mg propecia overnight delivery hair loss gastric sleeve. These techniques rely on photon–surface interactions and electron–surface interactions to provide chemical information about the oxide layer buy 1mg propecia hair loss reasons in women. They are restricted to the outermost surface because the signal generated comes only from the outer 5 nm or so of the surface. One limitation to many of these techniques involves the use of instruments that require very high vacuums and may alter or affect the nature of the surface. CORROSION-RESISTANT ORTHOPEDIC ALLOYS There are three principal metal alloys used in orthopedics and particularly in total joint replace- ment: titanium based alloys, cobalt based alloys, and stainless steel alloys. The elemental compo- sition of these three alloys is shown in Table 2. Alloy-specific differences in strength, ductility, and hardness generally determine which of these three alloys is used for a particular application or implant component. However, it is primarily the high corrosion resistance of all metal alloys that has led to their widespread use as implant materials. Implant alloys were originally developed for maritime and aviation uses where mechanical properties such as corrosion resistance and high strength are paramount. Stainless Steel Alloys The form of stainless steel most commonly used in orthopedic practice is designated 316LV (American Society for Testing and Materials F138, ASTM F138). The designation 316 classifies the material as austenitic, the L denotes the low carbon content, and V the vacuum under which it is formed. The carbon content must be kept at a low level to prevent carbide (chromium–carbon) accumulation at the grain boundaries. This carbide formation weakens the material by allowing a combination of corrosion and stress to degrade the material at its grain boundaries. In the past, elevated levels of carbon have been associated with the fracture of some orthopedic implants in vivo. Molybdenum is added to enhance the corrosion resistance of the grain boundaries, while chromium dissipated evenly within the microstructure allows the formation of chromium oxide (Cr2O3) on the surface of the metal. The ionic bonds associated with this coating protect the surface from electrochemical degradation. New Stainless Steels The relatively poor corrosion resistance and biocompatibility of stainless steels when compared to Ti and Co–Cr–Mo alloys provides incentive for development of improved stainless steels. New alloys such as BioDur 108 (Carpenter Technology Corp. This steel contains a high nitrogen content to maintain its austenitic structure and boasts improved levels of tensile yield strength, fatigue strength, and improved resistance to pitting corrosion and crevice corrosion as compared to nickel-containing alloys such as Type 316L (ASTM F138). Cobalt–Chromium Alloys Cobalt–chromium implant alloys fall into one of two categories, those with nickel and other alloying elements and those without. Of the many Co–Cr alloys available, the two most com- Corrosion and Biocompatibility of Implants 73 74 Hallab et al. Others approved for implant use include one that incorporates tungsten (Co–Cr–Ni–W, ASTM F-90) and another with iron (Co–Ni–Cr–Mo–W-Fe, ASTM F-563). Co–Ni–Cr–Mo alloys that contain large percentages of Ni (25–37%) promise increased corrosion resistance yet raise concerns of possible toxicity and/or immunogenic reactivity (discussed later) from released Ni. The biologic reactivity of released Ni from Co–Ni–Cr alloys is cause for concern under static conditions. Due to their poor frictional (wear) properties, Co–Ni–Cr alloys are also inappropriate for use in articulating components. Therefore the dominant implant alloy used for total joint components remains Co–Cr–Mo (ASTM F-75). Titanium Alloys While CPTi is most commonly used in dental applications, the stability of the oxide layer formed on CPTi (and consequently its high corrosion resistance) and its relatively higher ductility (i. Generally, Ti-6Al-4V (ASTM F-136) is used for joint replacement components because of its superior mechanical properties in comparison to CPTi (Table 3). The Ti-6Al-4V alloy (also known as Ti-6-4) is composed of grains of two phases: an HCP phase and a BCC phase, referred to as the alpha and beta phases, respectively. The microstructure and mechanical properties of this alloy are highly dependent on the thermomechanical processing treatments. The Ti-6Al-4V alloy microstructure is generally composed of a fine-grained HCP phase with a sparse distribution of the BCC phase. If the material is cooled too slowly the BCC phase becomes more prominent and lowers the strength and corrosion resistance of the alloy.

While the impact of any lifestyle intervention is likely to be quite small for any one individual order 1mg propecia with mastercard hair loss on legs, the potential for “shifting to the right” the normal curve of bone mineral density could be significant cheap 1mg propecia free shipping hair loss 12 months postpartum. Although a great deal of the activity in this area is likely to come from voluntary organisations, the physician’s role as educator will expand as public expectations for accurate information and guidance from the medical community increases. Monitoring therapy There is some disagreement at present over how best to monitor the efficacy of interventions for osteoporosis and, indeed, whether this should be done at all. On the one hand, the majority of apparent non- responders are non-compliant or pursue a lifestyle which renders therapy ineffective and, since the number of true non-responders to the more efficacious treatments is low, it is arguable whether there is any role for monitoring of therapy (consistent with the principles of screening). On the other hand, it may be difficult to persuade patients to take long term therapy that does not result in symptomatic improvement and may cause side-effects, without some means of reassurance that the treatment is having the desired effect. There also remain unanswered questions regarding the period which should elapse before seeking a response to treatment, and conversely how soon a person should be considered a non-responder. Bone mineral density is the gold standard surrogate marker of fracture risk – how satisfactory is it in monitoring response to therapy? Also what impact will such information have on management (i. The rate of change in bone mineral density is greatest in the spine, and this site is therefore preferred for monitoring. The precision error of spine measurements is about 1%; a reliably detectable difference (2. At the hip, where rates of change in bone mineral density are less, it may take three or more years before the response to treatment can be assessed. Changes occurring in individuals over relatively short periods of time are difficult to interpret because of the imprecision of measurements and the phenomenon of regression to the mean. Within six months, reductions in resorption and formation markers have been noted; the degree of difference means that a statistically significant change is more readily identified. However, the correlation of these changes in turnover markers in an individual patient with increased bone mineral density, and more importantly with reduction of fracture rates, has yet to be established. If non-responders are identified early, there must be a hierarchy of treatment to identify “more potent” strategies to protect these patients. While some alternatives, particularly combinations of currently available therapies, will be investigated in the next few years, it remains to be seen whether those who do not respond to one strategy are likely to respond to an alternative – if not, the value of drug monitoring will certainly be challenged. Future delivery of osteoporosis care As in many disciplines, osteoporosis diagnosis and management will move to primary care and will be increasingly driven by protocols, algorithms and guidelines from international and local bodies, experts focussing instead on research, appraisal of new data and ensuring that guidelines continue to offer effective management. In the UK resources in the primary care setting are already increasing with the development of primary care trusts. Financial incentives for cost efficiency are increasingly dominant and elements of private care are returning. Options that an individual patient may believe to be worth the cost (akin to decisions about purchasing insurance) may not be cost effective for society (where cost to prevent one fracture is the dominant argument). This can easily be envisaged as applying to routine postmenopausal or treatment monitoring dual energy x ray absorptiometry, or to specific treatments (for example, anabolic therapies or even bisphosphonates). Worldwide, similar debates apply to all models of healthcare delivery. Where state-supported insurance schemes are in place, the underwriters may take an active role in requiring early detection and primary prevention, or may limit cover to those with established osteoporosis (already in place in much of Europe). An unacceptable burden of cost in caring for the elderly is predicted to fall on a diminishing young population. This has prompted proposals, including Tribunals for Maintenance of Parents (Singapore) where 94 MANAGEMENT OF OSTEOPOROSIS the elderly will have legal recourse to obtain a minimum standard of care from their relatives, or contributory insurance schemes to cover health care after 75 years of age (Europe). Despite the recent move by the pharmaceutical industry to provide antiretroviral therapy to the developing world to combat HIV/AIDS, it is highly unlikely that such philanthropic gestures will include osteoporosis. Therefore, the ageing population of South East Asia and South America, where up to 75% of hip fractures are predicted to occur over the next 30 years, is unlikely to benefit from the advances so eagerly anticipated here. The equitable reallocation of global resources to the world’s people is a discussion that extends far beyond any vision of osteoporosis.

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