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All these reflexes involve hard-wired circuits of the spinal © 2006 by Taylor & Francis Group purchase vermox 100 mg otc, LLC Functional Systems 123 Dorsal horn Intermediate gray Lateral motor n vermox 100mg with visa. THE PYRAMIDAL SYSTEM NEUROLOGICAL NEUROANATOMY DIRECT VOLUNTARY PATHWAY The cross-sectional levels for following this pathway The cortico-spinal tract, a direct pathway linking the cor- include the upper midbrain, the mid-pons, the mid- tex with the spinal cord, is the most important one for medulla, and cervical and lumbar spinal cord levels. After emerging from the internal capsule, the cortico- This pathway originates mostly from the motor areas spinal tract is found in the midportion of the cerebral of the cerebral cortex, areas 4 and 6 (see Figure 14A, peduncles in the midbrain (see Figure 6, Figure 7, next Figure 17, and Figure 60; discussed in Section B, Part III, illustration, and Figure 48). The cortico-spinal fibers are Introduction and with Figure 48). The well-myelinated then dispersed in the pontine region and are seen as bun- axons descend through the white matter of the hemi- dles of axons among the pontine nuclei (see Figure 66B). At the lowermost are then found within the medullary pyramids (see Figure level of the medulla, 90% of the fibers decussate and form 6 and Figure 7). Hence, the cortico-spinal pathway is often the lateral cortico-spinal tract, situated in the lateral aspect called the pyramidal tract, and clinicians may sometimes of the spinal cord (see Figure 68). The ventral cortico- refer to this pathway as the pyramidal system. At the spinal tract is found in the anterior portion of the white lowermost part of the medulla, most (90%) of the cortico- matter of the spinal cord (see Figure 68). Lesions involving the cortico-spinal tract in humans are Many of these fibers end directly on the lower motor quite devastating, as they rob the individual of voluntary neuron, particularly in the cervical spinal cord. This path- motor control, particularly the fine skilled motor move- way is involved with controlling the individualized move- ments. This pathway is quite commonly involved in ments, particularly of our fingers and hands (i. Experimental work with monkeys has arteries or of the deep arteries to the internal capsule shown that, after a lesion is placed in the medullary pyr- (reviewed with Figure 60 and Figure 62). This lesion amid, there is muscle weakness and a loss of ability to results in a weakness (paresis) or paralysis of the muscles perform fine movements of the fingers and hand (on the on the opposite side. The clinical signs in humans will opposite side); the animals were still capable of voluntary reflect the additional loss of cortical input to the brainstem gross motor movements of the limb. There was no change nuclei, particularly to the reticular formation. The innervation for the lower extremity is traumatic injuries (e. In this case, other pathways would be involved and the Those fibers that do not cross in the pyramidal decus- clinical signs will reflect this damage, with the loss of the sation form the anterior (or ventral) cortico-spinal nonvoluntary tracts (discussed with Figure 68). Many of the axons in this pathway will cross before of the spinal cord is damaged, the loss of function is terminating, while others supply motor neurons on both ipsilateral to the lesion. The ventral pathway is concerned with movements A Babinski sign (discussed in Section B, Part III, of the proximal limb joints and axial movements, similar Introduction) is seen with all lesions of the cortico-spinal to other pathways of the nonvoluntary motor system. The cortico-bulbar fibers do not form a includes the somatosensory nuclei, the nuclei single pathway. The fibers end in a wide variety of nuclei cuneatus and gracilis (see Figure 33). There is of the brainstem; those fibers ending in the pontine nuclei also cortical input to the periaqueductal gray, are considered separately (see Figure 48). These axons course via the internal capsule and continue into the cerebral CLINICAL ASPECT peduncles of the midbrain (see Figure 26). The fibers Loss of cortical innervation to the cranial nerve motor involved with motor control occupy the middle third of nuclei is usually associated with a weakness, not paralysis, the cerebral peduncle along with the cortico-spinal tract of the muscles supplied. For example, a lesion on one side (described with the previous illustration; see Figure 48), may result in difficulty in swallowing or phonation, and supplying the motor cranial nerve nuclei of the brainstem often these problems dissipate in time. A patient with such a lesion will • Cranial Nerve Nuclei: The motor neurons of be able to wrinkle his or her forehead normally on both the cranial nerves of the brainstem are lower sides when asked to look up, but will not be able to show motor neurons (see Figure 8A and Figure 48); the teeth or smile symmetrically on the side opposite the the cortical motor cells are the upper motor lesion. Because of the marked weakness of the muscles neurons. These motor nuclei are generally of the lower face, there will be a drooping of the lower innervated by fibers from both sides, i. This will also affect nucleus receives input from both hemispheres.

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This method was used to compare unmodified and photopolymer-modified biomaterials (Figure 4) vermox 100mg low price. All of the biomaterials tested are frequently used in medical devices because of their desirable bulk properties purchase vermox 100mg. Without any surface modification, these materials demonstrate a wide range of relatively high contact angles; such hydrophobicity can compromise device performance and efficacy. Modification of the substrates with hydrophilic photopolymers results in significant reduction in contact angle (increase in wettability) for all materials tested, and all surface-modified materials approach a similar contact angle value. This is not surprising, since any surface modified with the same hydrogel should have essentially the same wetting characteristics, regardless of the substrate polymer. Lubricity Lubricity is a desirable attribute for medical devices that require movement against sensitive tissues, such as with a urinary tract catheter. Without this characteristic, blood vessel walls Surface Modification of Biomaterials 103 Figure 4 Improved wettability by surface modification with photoactivatable hydrophilic polymers. The materials were modified with a mixture of photopolymers containing polyacrylamide, polyvinylpyrrolidone and polyethylene glycol. The materials are silicone rubber (SR), polypropylene (PP), polysulfone (PSF), polyvinylchloride (PVC), polystyrene (PS), polyethylene (PE), polycarbonate (PC), polymethylmethacry- late (PMMA), and polyurethane (PU). Hydrophilic, lubricious coatings reduce friction and significantly reduce tissue damage relative to hydrophobic materials. In addition to the damage caused by hydropho- bic surfaces, the device itself may not function properly if it generates too much friction in use. The wide variety of biomaterials used in medical devices has an equally wide distribution of surface frictional properties. These properties range from pliable, tacky, low-durometer sili- cones to the smooth hard surfaces of ultra high molecular weight polyethylene (UHMWPE) and Teflon. In many cases, such as with intravascular catheters, the flexible materials are critical to device function since the material must yield to the shape of the vasculature as it is being fed into the body. Lubricious coatings can dramatically improve ease of use since they can slide more readily into place. The ideal biomaterial for these types of applications should be both flexible and slippery. Lubricity is measured by determining the force needed to push or pull an object through a pathway that has some resistance. The coefficient of friction (ratio of pull or push forces to the normal, or load force) is one way of quantifying the lubricity values. Often the pull or push forces are stated by themselves along with a description of the test method. The lubricity of a coating is strongly dependent on the material against which the part is being tested. The biomate- rial is typically hydrated prior to testing in order to provide the fluid film necessary to cushion the tissue–device interaction. A sled with a known weight applied to it can be pulled across the biomaterial to measure friction. Alterna- tively, the sample can be squeezed between two vertical pads and drawn through them. In other cases, a pathway can be created that simulates the appropriate anatomy (e. The testing can be cycled multiple times to determine if the frictional forces change over time. Durability of a particular coating can be as important as the initial lubricity, especially for coatings applied to devices that are used for extended periods of time or are subject to extensive manipulation. Figure 5 shows the force needed to pull stainless steel wires through two sub- merged silicone pads that have been compressed with 500 g of force. The wire that was coated with Teflon, a lubricious yet very hydrophobic material, required about half the force of an uncoated wire to pull it through the fixture. In comparison, the wire that had a lubricious, hydrophilic, photoimmobilized polymer coating required less than a tenth of the force of an uncoated wire. The hydrophilic coating was durable for many cycles of the test. A wide range of biomaterials have been modified with photoimmobilized hydrophilic polymers and tested against various surfaces. Lubricious surfaces on medical devices reduce the force required to manipulate medical devices during a surgical procedure.

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Milwaukee Area Technical College Massasoit Community College Milwaukee cheap 100mg vermox amex, Wisconsin Brockton purchase vermox 100mg otc, Massachusetts Sharon Ewing, PhD, FNP, RN, CS Kelly McManigle, RN, BSN University of Arizona, College of Manatee Technical Institute Nursing Bradenton, Florida Tucson, Arizona Jo Ann Nicoteri, PhD(c), MS, CS, Nicole Harder, RN, MPA CRNP, BC University of Manitoba University of Scranton Winnipeg, Manitoba, Canada Scranton, Pennsylvania Janet Ihlenfeld, RN, PhD Michael Rackover, PA-C, M. D’Youville College Philadelphia University Buffalo, New York Philadelphia, Pennsylvania Clair Kaplan, RN/MSN, APRN Nancy Watts, RN, MN, PNC (WHNP), MHS, MT (ASCP) London Health Sciences Centre Yale School of Nursing London, Ontario, Canada New Haven, Connecticut Sally Weiss, RN, MSN, EdD Joyce Kunzelman, RN, BScN, GNC(C) Nova Southeastern University Interior Health Authority of British Fort Lauderdale, Florida Columbia Vernon, British Columbia, Canada Jennifer Whitley, RN, MSN, CNOR Huntsville Hospital Jocelyn Loftus, MSN, APRN, BC Huntsville, Alabama Simmons College Boston, Massachusetts ix Copyright © 2006 F. Contents Part 1: The Art of Assessment and Clinical Decision Making 1 Chapter 1: Assessment and Clinical Decision-Making: An Overview 2 History 2 Physical Examination 3 Diagnostic Studies 4 Diagnostic Statisties 4 Clinical Decision-Making Resorces 6 The Diagnostic Process 7 Summary 9 Suggested Readings 10 Part 2: Advanced Assessment and Differential Diagnosis by Body Regions and Systems 11 Chapter 2: Skin 12 History 12 General Integumentary History 12 Past Medical History 13 Family History 13 Habits 13 Physical Examination 13 Order of the Exam 13 Assessing Skin Lesions 16 Differential Diagnosis of Common Chief Complaints 17 Vesicles (Blisters) 17 Bullae (Large Blisters) 20 Pustules 20 Keratotic Lesions 21 Raised, Skin-Colored Lesions 22 White Lesions 24 Brown Lesions 25 Inflammatory or Red Lesions 26 Eczematous Lesions with Excoriations 30 Suggested Readings 31 Chapter 3: Head, Face, and Neck 32 History 32 General History 32 Past Medical History 33 Family History 33 Habits 33 Physical Examination 33 xi Copyright © 2006 F. Contents Differential Diagnosis of Chief Complaints 33 Head Pain and Headache 33 Jaw Pain and Facial Pain 35 Facial Swelling 39 Facial Numbness 41 Scalp and Face Pruritus 42 Neck Fullness/Mass or Pain 43 Difficulty Swallowing 47 Suggested Readings 49 Chapter 4: The Eye 51 History 51 General Eye History 51 Past Medical History 51 Family History 52 Habits 52 Physical Examination 53 Order of the Examination 53 Visual Acuity 53 Peripheral Vision 53 Alignment 53 Accessory Structures 53 External Eye Structures 53 Pupils 53 Anterior Chamber and Lens 53 Cranial Nerves 53 Funduscopic Examination 56 Differential Diagnosis of Chief Complaints 57 Visual Disturbances 57 Reddened Eye 64 Eye Pain 69 Eye Discharge 71 Ptosis 72 Double Vision 74 Suggested Readings 75 Chapter 5: Ear, Nose, Mouth, and Throat 77 History 77 General History 77 History of the Present Illness 77 Past Medical History 79 xii Copyright © 2006 F. Contents Family History 80 Habits 80 Review of Systems 80 Physical Examination 80 Order of the Examination 80 Differential Diagnosis of Chief Complaints: Ear 84 Ear Pain (Otalgia) 84 Ear Discharge (Otorrhea) 88 Decreased Hearing or Hearing Loss 90 Ringing (Tinnitus) 94 Ear Fullness 95 Differential Diagnosis of Chief Complaints: Nose 96 Bleeding (Epistaxis) 96 Congestion and/or Drainage 100 Loss of Smell 102 Differential Diagnosis of Chief Complaints: Mouth 102 Mouth Sores (Painful and Painless) 102 Mouth Pain Without Obvious Lesions 108 Differential Diagnosis of Chief Complaints: Throat 109 Sore Throat or Throat Pain 109 Hoarseness 114 Suggested Readings 116 Chapter 6: Cardiac and Peripheral Vascular Systems 117 Cardiac System 117 Anatomy and Physiology 117 Heart Sounds 117 The Cardiac Cycle 119 History 120 General History 120 Past Medical History 121 Family History 121 Habits 121 Physical Examination 121 General Assessment 121 Inspection 122 Auscultation 122 Palpation 123 Percussion 123 Cardiovascular Laboratory Tests 123 xiii Copyright © 2006 F. Contents Differential Diagnosis of Chief Complaints 124 Palpitations or Arrhythmia 124 Irregular Pulse 126 Chest Pain 128 Patient History of Heart Murmur 132 Elevated Blood Pressure 138 History of Elevated Lipids 140 Difficulty Breathing and Shortness of Breath 142 Acute and Subacute Bacterial Endocarditis 145 Peripheral Vascular System 145 Differential Diagnosis of Chief Complaints 146 Peripheral Edema 146 Leg Pain 148 References 150 Chapter 7: Respiratory System 152 History 152 Symptom Analysis 152 Past Medical and Family History 153 Habits 153 Physical Examination 154 Inspection 154 Palpation 154 Percussion 155 Auscultation 155 Diagnostic Studies 156 Imaging Studies 157 Differential Diagnosis of Chief Complaints 157 Cough 157 Shortness of Breath and Dyspnea 162 Wheezing and Chest Tightness 164 Hemoptysis 165 Pleuritic Pain 165 References 167 Suggested Readings 167 Chapter 8: Breasts 168 History 168 General History: Symptoms Analysis and Review of Systems 169 Past Medical History 169 Family History 169 Habits 169 xiv Copyright © 2006 F. Contents Physical Examination 169 Order of the Examination 170 Special Considerations 171 Differential Diagnosis of Chief Complaints 172 Breast Mass 172 Breast Pain 175 Breast Discharge 178 Male Breast Enlargement or Mass 180 Reference 182 Suggested Readings 182 Chapter 9: Abdomen 183 History 183 General History 183 Past Medical History 184 Family History 184 Habits 184 Physical Examination 184 Order of the Examination 184 Special Maneuvers 187 Differential Diagnosis of Chief Complaints 189 Abdominal Pain 189 Nausea and Vomiting 207 Diarrhea 212 Constipation 217 Jaundice 221 Gastrointestinal Bleeding 225 References 228 Suggested Readings 228 Chapter 10: Genitourinary System 229 History 230 General History 230 Past Medical and Surgical History 230 Family History 230 Sexual History 231 Physical Examination 231 General History 231 Patterns of GU Pain 231 Diagnostic Studies 232 Laboratory Evaluation 232 Radiologic Evaluation 234 xv Copyright © 2006 F. Contents Differential Diagnosis of Chief Complaints 237 General Complaints 237 Lower Urinary Tract Symptoms 248 Urinary Incontinence 256 References 258 Suggested Readings 259 Chapter 11: Male Reproductive System 260 History 260 General History 260 Past Medical History 260 Family History 261 Sexual History 261 Habits 261 Physical Examination 262 Order of the Examination 262 Special Maneuvers 262 Differential Diagnosis of Chief Complaints 264 General Complaints 264 Erectile Function Complaints 277 Complaints Related to Male Fertility and Sexual Function 284 References 288 Chapter 12: Female Reproductive System 289 Anatomy and Physiology Reproductive Hormones 289 History 291 General History 291 Past Medical History 293 Habits 293 Physical Examination 294 Order of the Examination 294 Differential Diagnosis of Chief Complaints 295 Mass and/or Swelling at the Introitus 295 Vaginal Discharge 299 Labial Lesions 304 Abnormal Pap Smear 307 Dysfunctional Uterine Bleeding 308 Amenorrhea 312 Dysmenorrhea 315 Ovarian Cancer 316 Sexual Dysfunction 318 xvi Copyright © 2006 F. Contents Dyspareunia 319 Infertility 320 References 320 Chapter 13: Musculoskeletal System 321 Anatomy and Physiology 321 Bones and Joints 322 Assessment of Musculoskeletal Complaints 322 History 322 General Musculoskeletal History 322 Past Medical History 323 Family History 323 Habits 323 Physical Examination 324 Order of the Examination 324 Range of Motion 325 Ligamentous Tests 325 Muscle Strength and Tone 325 Special Maneuvers 326 Diagnostic Studies 326 Differential Diagnosis of Chief Complaints 326 Joint Pain 327 Polyarthralgia 327 Neck Pain 331 Low Back Pain 335 Isolated or Limited Joint Pain 339 Shoulder Pain 339 Elbow Pain 342 Wrist and Hand Pain 343 Hip Pain 344 Knee Pain 346 Ankle and Foot Pain 350 Myalgia 351 Conclusion 352 Suggested Readings 353 Chapter 14: Neurological System 354 History 354 Chief Complaint and the History of Present Illness 354 General History and the Review of Systems 354 Medical and Surgical History 355 General Neurologic History 355 xvii Copyright © 2006 F. Contents Social History 355 Family History 355 Physical Examination 355 General Appearance and Affect 356 Mental Status 356 Cranial Nerve Examination 357 Motor Function 357 Reflexes 358 Coordination 358 Cerebrovascular 358 Fundoscopic Examination 359 Sensory Examination 359 Differential Diagnosis of Chief Complaints 359 Headache or Cephalalgia 359 Altered Mental Status 369 Dizziness and Vertigo 373 References 377 Suggested Readings 378 Chapter 15: Nonspecific Complaints 379 History and Physical Examination 379 Differential Diagnosis of Chief Complaints 379 Fatigue 379 Weakness 386 Fever of Unknown Origin 389 Unexplained Weight Loss 391 Suggested Readings 394 Chapter 16: Psychiatric Mental Health 395 Comprehensive Psychiatric Evaluation 396 Problem Identification and Chief Complaint 396 History of Present Illness 396 Pertinent Past Psychiatric History 396 Pertinent Social History 396 Pertinent Family History 397 Medical History and the Review of Symptoms 397 Mental Status Examination 397 Assessing for Potential Medical Mimics 398 Differential Diagnosis oF Chief Complaints 398 Anxiety 398 Mood Disorders 402 xviii Copyright © 2006 F. Contents Substance-Related Disorders 408 Eating Disorders 411 Thought Disorders 414 Issues Related to Older Adults 418 References 419 Suggested Readings 419 PART 3: Assessments and Differential Diagnosis with Special Patient Populations 421 Chapter 17: Pediatric Patients 422 Communicating with Infants and Children During the Pediatric Assessment 422 Infants 422 Toddlers 422 Preschoolers 423 School-Age Children 423 Adolescents 423 Pediatric History and Physical Examination 423 Head 424 Eyes 424 Ears 425 Nose and Sinuses 425 Mouth and Throat 426 Lungs 426 Heart 427 Breasts 427 Abdomen 429 Genitourinary System 430 Musculoskeletal System 431 Neurological System 434 Skin 434 Growth and Development 436 Physical Growth 436 Development by Age 437 Hearing/Speech 442 Vision 443 Nutrition 444 Anticipatory Guidance and Safety 446 Teething and Tooth Eruption 446 Suggested Readings 449 xix Copyright © 2006 F. Contents Chapter 18: Pregnant Patients 451 History 451 Physical Examination 452 Laboratory Studies 454 Prenatal Education 454 Common Chief Complaints and Discomforts of Pregnancy 456 GI Complaints 456 Abdominal Pain 458 Musculoskeletal Complaints 458 Respiratory Complaints 460 Fatigue 462 Genitourinary Complaints 462 Circulatory Complaints 463 Pregnancy Complications 464 Anemia 464 Gestational Diabetes 466 Hypertension 468 Vaginal Bleeding 469 Vaginal Infections 470 Urinary Tract Infections 471 Size Not Equal to Dates 471 Preterm Labor 473 Summary 474 References 474 Suggested Readings 475 Chapter 19: Older Patients 477 The Demographics of Aging 478 The Approach to the Assessment of Older Individuals 479 The Physiology of Aging 480 Functional Assessment 483 Measures of Function 483 Measures of Cognitive Function 483 The Atypical Presentation of Common Conditions 489 Case Analysis 490 Geriatric Syndromes 492 The Assessment of Driving Safety 494 General History 494 Focused History 494 Habits 495 xx Copyright © 2006 F. Contents Physical Examination 495 Resources 496 Head, Eyes, Ears, Nose, and Mouth 497 Neuromuscular System 498 Nutritional Assessment 500 Advance Care Planning 503 Conclusion 504 References 504 Index 506 xxi Copyright © 2006 F. PART 1 The Art of Assessment and Clinical Decision- Making Copyright © 2006 F. Chapter 1 Assessment and Clinical Decision-Making: An Overview linical decision-making is often fraught with uncertainties. However, expert diagnosticians are able to maintain a degree Cof suspicion throughout the assessment process, to consider a range of potential explanations, and then to generate and narrow their differential diagnosis, based on their previous experience, famil- iarity with the evidence related to various diagnoses, and under- standing of their individual patient. Through the process, they perform assessment techniques involved in both the history and physical examination in an effective and reliable manner and select appropriate diagnostic studies to support their assessment. Mary Jo Goolsby & Laurie Grubbs HISTORY Among the assessment techniques that are essential to valid diagno- sis is the performance of a “fact-finding” history. To obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverbal language, and be able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’s statements, they clarify any areas of uncertainty. The expert history, like the expert physical examination, is informed by the knowledge of a wide range of conditions, their physiologic basis, and their associated signs and symptoms. The ability to draw out descriptions of the patient’s symptoms and experiences is important, as only the patient can tell his or her story. To assist the patient in describing a complaint, a skillful inter- viewer knows how to ask salient questions to draw out necessary information without straying. A shotgun approach, with lack of focus, is not recommended and the provider should know, based on the chief complaint and any preceding information, what other ques- tions are essential to the history. It is important to determine the capacity of the symptom to bring the patient to the office, that is, the 2 Copyright © 2006 F. Assessment and Clinical Decision-Making: An Overview 3 significance of this symptom to the patient. This may uncover anxiety that the patient has about a certain symptom and why. It may also help to determine severity in a stoic patient who may underestimate or underreport symptoms. Throughout the history, interviewers recognize that patients may forget details, so prob- ing questions may become necessary. Moreover, patients sometimes have trouble finding the precise words to describe their complaint.

Mechanical Equipment & Den Hub & Pneumatic injectors: Mesalyse 276 & LEIBASCHOFF AND STEINER Electrical Equipment Electronic injectors: DHN1 100mg vermox sale, DHN2 vermox 100 mg with mastercard, DHN3, DHN4, and Dermotherap mesogun Pistor Gun Pistor developed a very light, somewhat noisy multinozzle injector made of plastic, with the capacity to regulate the depth of the needle from 1 mm onward. However, these injectors report the loss of infiltrate from one-thirds to two-thirds of the total volume. It has the advantage of its lesser price and the disadvantages of the loss of the drug and the noise. There are now new electronic guns that do not waste drugs. The following are important points in mesotherapy (20,21): & Diffusion and distribution of the medicine is slower through the mesotract than through rest of the parenteral tracts. MESOTHERAPY FOR CELLULITE & 277 & Diffusion does not depend on the anatomical puncture location but on a perfect mesoexecution technique. Drugs for use in cellulite mesotherapy (22): & Benzopirone o lymphokinetic action & Pentoxifylline o hemorrheologic action & Theophylline o lipolytic action & TRIAC o lipolytic action & Caffeine o lipolytic action & Carnitine o lipolytic action & Cynara scolymus o lower lipolytic action & Monomethyl Silanol o action over the connective tissue & Yohimbine o action over the alpha-2 adrenergic receptors & Buflomedil o vasodilatation & Procaine o anesthetic and more & Phentolamine o action over the alpha-2 adrenergic receptors & DRUGS AND PRODUCTS USED IN MESOTHERAPY DISINFECTANTS There are many disinfectants that can be used on the skin, such as chlorhexidine, chloride of benzalconio, alcohol, ether, etc. However, it is preferable to use an alcoholic solution of Betadine (1%, colorless) prior to the mesotherapy due to its powerful action on bacteria, virus, and the majority of the fungus. Subsequent to the treatment session, it is advisable to clean the skin with 70% ethyl alcohol. AESCULUS (23) This homeopathic drug has the property of vitamin P, and normally affects the degree of capillary and membrane permeability. It contains escin with a high activity in microvascu- larization, antiedema, and anti-inflammatory processes. CONJOCTYL (SALICYLATE OF MONOMETILSILANOTRIOL) (24) Silicon is an element in the structure of elastic connective tissue. It enters the makeup of the macromolecules that form the woven connective tissue: elastin, collagen, proteoglycan, and glycoprotein. Regarding its structure, it possesses increased lipolytic action over theo- phylline, aminophylline, and caffeine. A reduction in the destruction is produced by elastin and collagen, with limitations to the destruction of connective tissue and its sclerosis. It reorganizes the lipids in the cell membrane, thus increasing its resistance to peroxide damage. CHOFITOL: (EXTRACT OF ALCACHOFA–C SCOLYMUS) (25) Actions & increases the volume of bile secreted & antitoxic function of the liver & glycogenic function of the liver & metabolism of the lipids & metabolism of cholesterol Indications: & phytotherapy to stimulate biliary function & symptomatic processing of the dyspeptic changes & excess blood urea; complementary processing of urinary lithiasis & hypercholesterolemia & cellulite MELILOTUS-RUTOSIDO´ (26) It has a pH of 6. It has an antispasmodic effect on the smooth muscle fibers of the lymphatic system and the capil- laries, thus diminishing permeability and increasing vascular resistance. MESOTHERAPY FOR CELLULITE & 279 PROCAINE It is best known for its anesthetic property. It is three to four times less powerful than cocaine. Procaine is used in mesotherapy in the form of chlorhydrate of procaine, 1% to 2%, with a molecular weight of 272. Actions & Local: has a short-term anesthetic effect due to the stabilization action of the mem- branes that oppose ionic transmembrane migration. Precautions & Dosage of procaine should be advised by a physician, since an overdose may result in complications such as agitation, delirium, trembling or lack of motor coordination, and drowsiness. In case of collapse, an injection of caffeine must be administered immediately. Secondary Effects & exceptional allergic dermatitis & asthma & anaphylactic shock & muscle paralysis & nausea, vomiting, and irritability & agitation BUFLOMEDIL It opens the precapillary sphincter, improving microcirculation (31). CAFFEINE With regard to lipid deposits, it is well known that caffeine causes an increase in the intra- cellular concentration of cyclic AMP (acid adenosın-5-monophosphoric´ cyclic) and has immediate consequences on the lipid metabolism of adipose tissues, thus increasing the levels of the cyclic AMP (32). The activation of the lipase into the fat cell lipase hormone promotes hydrolysis of triglycerides ‘‘in situ,’’ giving rise to the corresponding formation of glycerol and fatty acids. L-CARNITINE L-carnitine, ‘‘the decorative molecule of fat,’’ is an amino acid that constitutes an essential cofactor in the metabolism of fatty acids acting to diminish triglycerides and of total cholesterol by improving lipid metabolism (33).

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