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In other words impotence of psychogenic origin purchase super p-force 160 mg otc, can the test accurately detect whether a specific genetic variant is present or absentfi Additionally erectile dysfunction medication purchase super p-force 160 mg with visa, the state of New York requires information on clinical validity for all laboratory tests performed for people living in that state erectile dysfunction exercise video super p-force 160 mg with mastercard. Consumers erectile dysfunction herbal treatment generic 160 mg super p-force amex, health providers, and health insurance companies are often the ones who determine the clinical utility of a genetic test. It can be difficult to determine the quality of a genetic test sold directly to the public. If providers of direct-to-consumer genetic tests offer easy-to-understand information about the scientific basis of their tests, it can help consumers make more informed decisions. It may also be helpful to discuss any concerns with a health professional before ordering a direct-to-consumer genetic test. The Genetic Alliance offers information about the quality of genetic tests and current public policy issues. The World Health Organization discusses quality and safety in genetic testing. The results of genetic tests are not always straightforward, which often makes them challenging to interpret and explain. Therefore, it is important for patients and their families to ask questions about the potential meaning of genetic test results both before and after the test is performed. When interpreting test results, healthcare professionals consider a person’s medical history, family history, and the type of genetic test that was done. A positive test result means that the laboratory found a change in a particular gene, chromosome, or protein of interest. Depending on the purpose of the test, this result may confirm a diagnosis, indicate that a person is a carrier of a particular genetic mutation, identify an increased risk of developing a disease (such as cancer) in the future, or suggest a need for further testing. Because family members have some genetic material in common, a positive test result may also have implications for certain blood relatives of the person undergoing testing. It is important to note that a positive result of a predictive or presymptomatic genetic test usually cannot establish the exact risk of developing a disorder. Also, health professionals typically cannot use a positive test result to predict the course or severity of a condition. A negative test result means that the laboratory did not find a change in the gene, chromosome, or protein under consideration. This result can indicate that a person is not affected by a particular disorder, is not a carrier of a specific genetic mutation, or does not have an increased risk of developing a certain disease. It is possible, however, that the test missed a disease-causing genetic alteration because many tests cannot detect all genetic changes that can cause a particular disorder. This type of result is called uninformative, indeterminate, inconclusive, or ambiguous. An uninformative result cannot confirm or rule out a specific diagnosis, and it cannot indicate whether a person has an increased risk of developing a disorder. In some cases, testing other affected and unaffected family members can help clarify this type of result. For more information about interpreting genetic test results: the National Cancer Institute fact sheet Genetic Testing for Hereditary Cancer Syndromes. The National Women’s Health Resource Center offers a list of questions about genetic testing. The cost of genetic testing can range from under $100 to more than $2,000, depending on the nature and complexity of the test. The cost increases if more than one test is necessary or if multiple family members must be tested to obtain a meaningful result. Some states cover part of the total cost, but most charge a fee of $15 to $60 per infant. From the date that a sample is taken, it may take a few weeks to several months to receive the test results. Results for prenatal testing are usually available more quickly because time is an important consideration in making decisions about a pregnancy. The doctor or genetic counselor who orders a particular test can provide specific information about the cost and time frame associated with that test. For more information about the logistics of genetic testing: EuroGentest offers a fact sheet about genetic testing laboratories Health insurance providers have different policies about which tests are covered, however. A person interested in submitting the costs of testing may wish to contact his or her insurance company beforehand to ask about coverage. Genetic testing has potential benefits whether the results are positive or negative for a gene mutation. Test results can provide a sense of relief from uncertainty and help people make informed decisions about managing their health care. For example, a negative result can eliminate the need for unnecessary checkups and screening tests in some cases. A positive result can direct a person toward available prevention, monitoring, and treatment options. Newborn screening can identify genetic disorders early in life so treatment can be started as early as possible. For more information about the benefits of genetic testing: EuroGentest offers a fact sheet about genetic testing Additional information about the potential benefits of genetic testing. The physical risks associated with most genetic tests are very small, particularly for those tests that require only a blood sample or buccal smear (a method that samples cells from the inside surface of the cheek). The procedures used for prenatal testing carry a small but real risk of losing the pregnancy (miscarriage) because they require a sample of amniotic fluid or tissue from around the fetus. Many of the risks associated with genetic testing involve the emotional, social, or financial consequences of the test results. In some cases, genetic testing creates tension within a family because the results can reveal information about other family members in addition to the person who is tested. The possibility of genetic discrimination in employment or insurance is also a concern. Another major limitation is the lack of treatment strategies for many genetic disorders once they are diagnosed. A genetics professional can explain in detail the benefits, risks, and limitations of a particular test. It is important that any person who is considering genetic testing understand and weigh these factors before making a decision. Additional information about the risks and limitations of genetic testing. Genetic discrimination occurs when people are treated differently by their employer or insurance company because they have a gene mutation that causes or increases the risk of an inherited disorder. Fear of discrimination is a common concern among people considering genetic testing. Several laws at the federal and state levels help protect people against genetic discrimination. Once granted a gene patent, the holder of the patent dictates how the gene can be used, in both commercial settings, such as clinical genetic testing, and in noncommercial settings, including research, for 20 years from the date of the patent. Gene patents have often resulted in companies having sole ownership of genetic testing for patented genes. For more information about gene patenting and the Supreme Court ruling: Read the Supreme Court ruling. The National Human Genome Research Institute discusses the relationship between Intellectual Property and Genomics The main differences between clinical genetic testing and research testing are the purpose of the test and who receives the results. The goals of research testing include finding unknown genes, learning how genes work, developing tests for future clinical use, and advancing our understanding of genetic conditions. The results of testing done as part of a research study are usually not available to patients or their healthcare providers. Clinical testing, on the other hand, is done to find out about an inherited disorder in an individual patient or family. People receive the results of a clinical test and can use them to help them make decisions about medical care or reproductive issues. It is important for people considering genetic testing to know whether the test is available on a clinical or research basis.

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External limiting membrane—It lies between rods and cones and outer nuclear layers impotence at 17 order super p-force 160 mg on-line. Outer plexiform layer—It consists of arborizations of the axons of rods and cones nuclei with the dendrites of the bipolar cells psychological erectile dysfunction young purchase 160mg super p-force with visa. Inner plexiform layer—It consists of synapses of the axons of the bipolar cells with the dendrites of the ganglion cells erectile dysfunction in diabetes mellitus ppt discount super p-force line. The choriocapillaris of the choroid supplies the pigment epithelium erectile dysfunction at age 31 cheap super p-force online visa, the layers of rods and cones and the outer nuclear layers. The normal artery: vein ratio is 2: 3 Nutritional support for the sensory retina comes largely from the Muller cell which spans almost the entire thickness of the retina. The visual impulses reach occipital cortex after 124 m sec following retinal stimulation. The central part (macula lutea) consists mainly of cones which are responsible for vision in the day light and for colour vision. The peripheral part of retina consists mainly of rods which are responsible for vision at night. Eale’s disease Symptom Usually none but there may be sudden impairment of vision due to vitreous haemorrhage. Peripheral neovascularisation is seen at the juction of perfused and non perfused areas of the retina. Retinitis proliferans—It follows large vitreous haemorrhage leading to fibrous tissue proliferation. Systemic corticosteroids are helpful in controlling the inflammation in early vasculitic stage. Vitrectomy with division of fibrous bands is recommended in cases of retinitis proliferans. Etiology There is exudation from the parafoveal or choroidal capillaries due to angiospasm and hyperpermeability which may be allergic or toxic in nature. Circular grey swelling about the size of the optic disc is seen over the macular region. Complications There may be geographic atrophy of pigment epithelium and choriocapillaries, fibrovascular scar formation and tears in the retinal pigment epithelium. Diagnosis Fluorescein angiography—It reveals leakage of dye through a defect in the Bruch’s membrane into the subretinal space. Ink-blot pattern—There are small hyperfluorescent spots which gradually increase in size. Smoke-stack pattern—There is a small hyperfluorescent spot which spreads vertically like a smoke stack and then gradually spread laterally to look like mushroom or umbrella. Reassurance is the only treatment in majority of patients as 80-90 percent cases resolve spontaneously within 4-12 weeks. Photocoagulation is effective in controlling the exudation process in long standing cases with marked loss of vision or recurrent cases. Etiology this is the most severe form of retinal telangiectasia with intraretinal and subretinal exudation. A large yellowish-white raised area or several smaller areas are seen posterior to the retinal vessels. Fluorescein angiography—Retinal vessels show abnormal coarse, net of dilated capillaries, irregular aneurysmal dilatation and leakage of dye. Complicated cataract occurs in posterior cortex due to disturbance to the nutrition of lens. In the early stage, treatment with photocoagulation or cryotherapy may be successful in preventing progression of the disease process and improving symptoms. Almost all the visible rays and many infrared rays (wavelength above 700 nm) are absorbed by the pigment epithelium causing severe retinal burn. Later on there is pigment deposition and retinal hole formation at the foveal region. Prophylaxis • Glasses impervious to infrared and ultraviolet rays should be used while looking at solar eclipse. Guarded prognosis is given although improvement often occurs with corticosteroids. Vascular retinopathies due to diabetes, hypertension, toxemia of pregnancy, nephritis. Intraretinal haemorrhage—When the haemorrhage from the retinal vessels is small and situated within the retinal tissue, it is known as intraretinal haemorrhage. The blood breaks the internal limiting membrane and the haemorrhage lies between the retina and vitreous. However, due to gravity the upper margin becomes horizontal after a few days as a result of sedimentation of red blood cells. Etiology It is usually due to an embolus or thrombosis along with spasm of the artery. It commonly occurs in cases of hypertension, arteriosclerosis, atherosclerosis, temporal arteritis or Buerger’s disease. Site of Occlusion the common site of origin of embolus is from common carotid artery in the neck, aorta or endocardium of the heart. It is invariably due to atheromatous embolus which is visible as a pale refractile body within the artery (Hollenhorst plaque). At times some central vision may persist due to presence of cilioretinal artery which supplies the macular area. The recovery of vision is due to the dislodgement of embolus into the peripheral arterioles. In partial or incomplete block the column of venous blood may break into red beads separated by clear interspaces which move to and fro (cattle truck appearance) by gentle pressure on the eyeball. Obstruction of a branch—Sector-shaped retinal pallor results with narrowing of one branch. Complete blindness may occur due to cystic or disciform degeneration of the macula. Prompt treatment is essential as anoxic retina is irreversibly damaged in about 90 minutes. In early stages the aim of the treatment is to relieve spasm and to remove the embolus into a peipheral branch of central retinal artery. It commonly occurs in elderly persons with cardiovascular diseases such as hypertension, arteriosclerosis, atherosclerosis and diabetes. In young persons it is usually caused by infective periphlebitis (branch occlusion) and local causes such as orbital cellulitis or facial erysipelas. Pathogenesis Obstruction to the outflow of blood and stagnation v Rise in intravascular pressure v Retinal oedema, abnormal leakage and haemorrhage v Formation of collaterals and neovasularisation Site of Occlusion It is just behind the lamina cribrosa where artery and vein share a common sheath. However, the loss of vision is not so sudden as in central retinal artery occlusion. Central retinal vein occlusion Superior temporal vein occlusion Pan photocoagulation Signs i. In branch vein occlusion • Oedema and haemorrhages are limited to the area supplied by the vein. Secondary neovascular glaucoma occurs at a later stage (usually within 3 months or 90 days) due to sclerosis and neovascularisation at the angle of anterior chamber (rubeosis iridis). Neovascular glaucoma can be prevented by panphotocoagulation of the retina or cryoapplication if the media is hazy. Panretinal photocoagulation should be given early when most of the intraretinal blood is absorbed. Hypertension is the most common vascular disease but visual loss secondary to hypertensive retinopathy is rare unlike diabetes mellitus. Predisposing Factors the following factors influence the development of hypertensive retinopathy, 1. Duration of hypertension—It is indicated by the degree of arteriosclerotic changes and retinopathy. In young—The primary response to systemic hypertension is narrowing of the retinal arterioles due to ‘spasm’. In aged—The response to systemic hypertension depends on the amount of pre-existing ‘involutional sclerosis’ or replacement fibrosis.

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Bone scans are also cally rogaine causes erectile dysfunction buy super p-force 160 mg without a prescription, it is a subluxation of the ligament rather than the radius jack3d causes erectile dysfunction buy 160mg super p-force otc. They may prefer holding the arm splinted close to top 10 causes erectile dysfunction order 160 mg super p-force free shipping Night pain is especially characteristic of both benign and the body erectile dysfunction korean red ginseng cheap super p-force 160mg without prescription, ofen giving the impression of wrist pain. Pain in is generally the key to diagnosis; x-ray fndings are nonspecifc the absence of local tenderness is another clue. Shin splints (medial tibial stress syndrome) are the most 9 common overuse injury of the lower leg. They present with “Burners” or “stingers” are transient neurologic injuries of 3 difuse tenderness along the lower third or half of the medial tibia; the brachial plexus due to compression or traction. Tranthe pain onset is initially toward the end of a period of exercise but sient severe unilateral pain extends from the shoulder to the with progression will be present throughout activity. Consider x-rays only if a stress fracTese injuries occur most commonly in football players and ture is suspected; pain due to stress fractures will be localized, wrestlers. If bilateral or afecting the lower extremities, spinal more severe, and present throughout activity. Radiographs will be normal in shin splints; Children and adolescents are more susceptible to physeal they may also be normal until afer 3 to 4 weeks of symptoms due 4 (growth plate) injury than ligament sprains or diaphyseal to a stress fracture. The 10 by ossifcation of the hematoma (myositis ossifcans), physical examination is normal. Pain that is unilateral, localized to causing pain and stifness for several months afer the injury. Complex regional pain syndrome (previously called refex 11 sympathetic dystrophy) is a rare condition presenting Nerve compression manifests with tingling, numbness, and acutely with intense extremity pain. Tere is either no history of 13 paresthesias (“pins and needles”) in addition to pain. Cartrauma or one of a very minor injury followed by acute pain, pal tunnel syndrome classically presents with numbness on the swelling, and color and temperature change of the afected area radial (thumb) side of the hand, and ulnar nerve entrapment days to weeks later. Erythema, warmth, and swelling occur inipresents with numbness on the ulnar side of the hand (fourth tially; chronically, disuse atrophy and cool, clammy skin develop. Although rare in children, cervical nerve comGrowing pains (benign nocturnal pains of childhood) are pression should be considered, especially if there is a history of 12 common. Children complain of bilateral difuse extremity neck trauma or symptoms are worse with the arm in an overpain, usually in the legs (thigh or calf). Ulnar nerve irritation or entrapment causes tingling, 17 numbness, and weakness of the fourth and ffh fngers. Plantar fasciitis is heel pain that may radiate over the entire 19 Localized tenderness over the anterior iliac crest characplantar fascial surface. Back pain is uncommon in children, especially chronic or sePresentation commonly includes a vague or dull backache that vere back pain. Most children who complain of back pain have may be worse at night; fever may or may not be present. Symptoms disease is tuberculosis spondylitis, a rare complication of unof severe or persistent back pain, as well as any abnormal fndtreated tuberculosis that is more likely to occur in children than ings on physical examination, mandate a thorough evaluation. As with adults, however, clear etiologies are not always identiIf pain persists, consider repeating x-rays versus obtaining fed, particularly in older children and adolescents without 7 other imaging in 2 weeks. In cases of suspected child The history should inquire about trauma, associated leg abuse, a bone scan should be considered early in the evaluation 1 pain, gait abnormalities, weakness, extremity pain or tinwhen initial x-rays are negative. Also ask Contusions and abrasions are the most common back in8 about aggravating or relieving factors (particularly whether it is juries sustained in routine play and sports in young chilrelieved with rest) and whether it wakes the patient from sleep. No additional workup is needed if no other injuries and The physical should include careful neurologic and abdominal an otherwise normal physical exam are present. The Back pain associated with bowel or bladder defcits, gait neurologic exam should include assessment of anal tone and (in 9 abnormalities, lower extremity pain, weakness, or refex or males) the cremasteric refex; a pelvic exam may be indicated in sensation defcits is suggestive of space-occupying lesions (spinal older adolescent females. The presence of associated abdominal pain, vomiting, dys2 Spondylolysis is a defect (stress fracture) of the bony conuria, hematuria, or vaginal complaints should prompt a 10 nection between a vertebral body and its arch (pars interspecifc evaluation for intraabdominal or pelvic problems. Spondylolisthesis is the forward slippage or vigilant for subtle neurologic signs and symptoms that may be displacement of one vertebra in relation to another. Common clinical fndings Children participating in sports involving repetitive fexion are back pain, limping, and a stif, straight posture due to loss of and hyperextension (gymnasts, football players, weight lifers) normal lumbar lordosis. Symptoms (poorly localto pick something up because of the pain related to spinal fexion. Younger children (,3 do not occur until the adolescent growth spurt; spinal hyperexyears of age) are more likely to present with a toxic picture of fetension typically exacerbates the pain. When symptoms do occur, they are children and adolescents may complain of back pain and pain not always consistent with the severity of the spondyolytic dewith walking and may or may not be febrile. In postural or fexible cases, it is fully correctable with voluntary efort, and any asSpinal x-rays or a bone scan may suggest the extent of 4 sociated pain is typically mild. Most cases of scoliosis, regardless of the age at onset, are Intraabdominal, retroperitoneal, or pelvic processes can idiopathic. If pain is noted with a scoliotic curve, carefully should aid in the diagnosis of problems such as pyelonephritis, consider infectious, infammatory, and neoplastic causes. The most common and sof tissues (muscles, tendons, bursae, cartilage) are sus13 ones are osteoid osteoma, osteoblastoma, and eosinophilic ceptible to overuse injuries. Presentation is typically a prolonged period of back and football players are particularly prone to overuse injuries pain (especially at night) that eventually evolves to stifness and of the back. Carrying a heavy book bag or backpack may cause (rarely) a painful scoliosis or mild neurologic defects. Overuse syndromes are more common in athletic adoles14 Bibliography cents than younger children. In Fleisher G, Ludwig S, editors: Textbook of pediatOveruse injuries result when repetitive activity without aderic emergency medicine, ed 6, Philadelphia, 2010, Lippincott Williams & quate conditioning or rest prohibits this resolution. Chapter 202 In meningitis, meningeal signs (nuchal rigidity, Kernig 7 and Brudzinski signs) are usually accompanied by sysChapter 47 temic signs of illness, including fever, altered consciousness, poor feeding, headache, and possibly seizures. Tumor of any origin (nerve, muscle, bone) may present Most causes of neck pain and stifness in children are benign; 8 acutely with a stif neck, owing to swelling or nerve comhowever, potentially life-threatening conditions (meningitis, cerpression. The history should clarify the onset, duration, and nature of 1 Hypermobility or instability of the occipitoatlantal or the the complaint and include a comprehensive review of sys9 atlantoaxial joints due to ligamentous hyperlaxity occurs tems. The physical examination should note stifness and range in up to 60% of children with Down syndrome. Tese children of motion of the neck (lateral movement and fexion-extension) are at an increased risk for spinal cord injury. Patients may be and the specifc nature and location of the pain (muscle spasm, asymptomatic or have slowly progressive neurologic symptoms muscle or bone tenderness). The diferential diagnosis for a child including neck pain, clumsiness or increased falling, change in who exhibits full mobility of their neck, even if it is painful, diftone, weakness, sensory defcits, or changes in bowel or bladder fers from that of a child whose range of motion is limited. The Special Olympics currently require cervical spine Torticollis or “wry neck” describes a condition in which the imaging for patients with Down syndrome prior to participainfant’s or child’s neck is tilted to one side and rotated to the tion in certain activities that may carry an increased risk of opposite side. Families, however, need to be ing mental status, cranial nerve involvement, upper extremity continually educated regarding worrisome signs and symptoms pain or weakness, and cerebellar function is important. The head is tilted toward a shortened sternoGrisel syndrome is a rare mild atlantoaxial subluxation that cleidomastoid muscle; a fbrotic mass is frequently palpable in the occurs in children without other risk factors for subluxation muscle belly. Other signs of intrauterine mechanical deformation (Down syndrome, connective tissue disorders, rheumatoid ar(plagiocephaly, facial asymmetry, foot deformities, developmental thritis) and in the absence of trauma. A suspected cervical spine injury should be treated in the 3 acute setting with cervical spine immobilization until apEye problems (nystagmus, superior oblique muscle weak10 propriate x-rays can be taken. The most common cervical spine subluxation involves the 4 atlantoaxial (C1-C2) joint. It may result from mild as well Neuroimaging may not be indicated if a drug efect is sus11 as severe trauma. Several antipsychotic and antiemetic medications cleidomastoid muscle tenderness, and torticollis. Symptoms of (most commonly haloperidol, prochlorperazine, and metoclospinal cord compression are rare in children. Oculogyric crisis is a dystonic reaction characterized Although clavicular fractures are usually indicated by loby torticollis and involuntary deviation and fxation of the gaze, 5 calized pain and tenderness, the predominant presenting usually upward.

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Lichen amyloidosis is the most common presentation of primary cutaneous amyloidosis erectile dysfunction causes tiredness buy genuine super p-force online. Clinical presentation involves discrete red-brown pruritic papules new erectile dysfunction drugs 2013 order 160mg super p-force free shipping, sometimes with keratotic scale impotence nerve damage cheap super p-force 160mg fast delivery, that coalesce into reticulated plaques erectile dysfunction at the age of 21 buy super p-force 160mg with mastercard. We present a case of 75-year-old woman with a 10-year history of a pruritic rash on her trunk and extensor surfaces of her extremities. Examination showed hyperpigmented papules coalescing into plaques covering her trunk, and reticulated plaques along her extremities. Biopsy demonstrated eosinophilic aggregates of amorphous material, and crystal violet stained focally positive for amyloid. After failing other regimens, the patient was started on thalidomide in addition to triamcinolone cream. After three months of treatment, the patient reported less pruritus, and examination showed a less extensive area of involvement. In our patient, treatment was well tolerated, and there was improvement in cutaneous findings. The symptomatic, with a target goal of controlblood count, complete metabolic panel, primary cutaneous forms are subdivided ling pruritus. Overall, treatment of lichen thyroid stimulating hormone and chest into macular amyloidosis, lichen amyloiamyloidosis is challenging and often X-ray were within normal limits. The patient failed a course of Atarax Lichen amyloidosis is the most common Typical histology shows acanthosis, (hydroxyzine) 25mg daily and triamcinopresentation of primary cutaneous amyloihyperkeratosis, and amyloid deposits in lone 0. Upon further contact, months following tion has been associated with numerous her previous visit, the patient reported connective-tissue diseases. She returned and was neous amyloidosis include: pachyonychia presented with a 10-year history of a restarted on therapy. At the time of her congenital, dyskeratosis congenital, familial pruritic rash on her trunk and extensor return, the lichenoid component was less palmoplantar keratoderma, scleroderma, surfaces of her extremities. Discussion amyloidosis includes hypertrophic lichen Examination showed hyperpigmented planus, lichen simplex chronicus, and papules coalescing into plaques covering the treatment of cutaneous amyloidosis papular mucinosis, making diagnosis chalher back and upper chest, and reticuis often challenging. The exact lated plaques along the extensor surfaces tion -breaking the rubbing/scratching etiology of amyloid deposition is unknown, of her arms and legs (Figure 1). Repeated biopsies of evidence and treatment experience is and formation of amyloid. N Engl Multiple Myeloma (in conjunction with dexamethasone) J Med 2007; 356: 2361-2371 10. Chin Med J (Engl) 1983; 96: 185-200 Prurigo Nodularis Preexisting hepatic or renal disease 12. Lichen amyloidosus: a relatively common Uremic Pruritus History of neuritis disorder in Taiwan. Lichen amyloidosis preBehcet’s disease Congestive Heart Failure senting as a popular pruritus syndrome in Human ImmuCutaneous lupus erythematosus Hypothyroidism nodeficiency Virus infected man. Erosive lichen planus betamethasone 17-valerate ointment in the treatment of lichen amyloidosis. Randomized comparison of thalidomide versus placebo in toxic epiderbeen found to be equally effective in small was shown to increase mortality compared mal necrolysis. Intern Med J 2006; 36: debridement, oral retinoids, keratinolytics, thought to be a sedative and have anti137-139 and cyclophosphamide. An intriguing case of priinflammatory and anti-malignancy mary amyloidosis with cardiac involvement: Symptomatic these treatments are partially effective at effects. The sedative effects have been and echocardiographic improvement with thalidomide best. Int J Cardiol 2006; 113: 141-143 demonstrated in activation of the sleep Thalidomide was introduced into center of the brain. In 1961, patients were treated with thalidomide and the drug was rapidly withdrawn from the dexamethasone at doses of 100mg daily, world market due to its teratogenicity. In drug back on the market as a therapeutic our patient, treatment was well tolerated alternative. Primary Localised Cutaneous Amyloidosis in In dermatology, thalidomide treatMalaysians. Clinical and ment has been used successfully in condihistopathological characteristics of primary cutaneous tions like sarcoidosis, lupus erythematous amyloidosis in 794 Chinese patients. Zhonghua Yi Xue Za Zhi (Taipei) 2001; 64: 101-107 profundus, porphyria cutanea tarda and 3. A clinical trial evaluating the use Photodermatology, Photoimmunology, and Photomediof thalidomide in the treatment of toxic cine 2001; 17: 42-43 5. The alence rate of less than one case per 10,000 patient had been treated with one course persons in all endemic countries. Brazil, of Medrol Dosepak eight months prior India, Madagascar, Mozambique and Nepal and had started on prednisone 10 mg/day are the five countries in which elimination Figure 1 two weeks prior to our evaluation, with still has not been achieved. He denied were approximately 259,000 new cases; any recent illnesses or travel outside the when leprosy was at its peak in 1998, there were 804,000 cases. He had associated symptoms of numbness and decreased Classification sensation to light touch within the lesions. Leprosy has a broad spectrum of clinical Differential diagnosis included leprosy presentations. Punch biopsies clinical, histologic, and bacterial presenof lesions on the abdomen and mid-back tations (see Table 1). Small satellite agent of leprosy, hence it is also known distributed on the trunk or limbs. Anesthesia in multibacillary cases before signs of overt cial, peripheral nerves are enlarged, tender within lesions is moderate. Anesthesia is often absent There are two major types of leprosy 8 by using Fite-Faraco stain; however, immuwithin the lesions. Lepromatous lesions are generalized However, treatment should not be stopped caseating granulomas, which are made 11 macules, papules, plaques or nodules that in the presence of either reaction. They may extend into little or no loss of sensation, and there are disease as a result of interaction between the epidermis, leaving no Grenz zone, and no signs of anhidrosis. Dermal nerves poor cell-mediated immunity and therefore leprae antigen, a type of delayed hyperdemonstrate edema and fibrosis that can have a multibacillary type of leprosy. Bacilli involvement occurs later in the disease in edema, ulceration and nerve damage. The relapse rate varies based on paucibacillary or multibacillary type, just over 1% and just under 1% respectively. For those patients with the multibacillary form who relapse, in addition to the two-year regimen it is also recommended to consider dapsone indefinitely to prevent further relapses. Outcome Our patient was immediately started on prednisone 20 mg a day, rifampin 300 mg twice a day and triamcinolone 0. The patient followed up in two weeks with marked improvement of his lesions and symptom of numbness. He has yet to experience any tion presents with fever, myalgias and arthleprosy reactions. Patients have multiorgan disease with conjunctivitis, synovitis, nephritis and orchitis, accompanied by tender erythemaReferences: tous nodules on extremities. Coordinating Center for Infectious Diseases/Division of BacteTreatment rial and Mycotic Diseases. Canada: Saunon the number of skin lesions and bacilli ders Elsevier, 2006 present. McGraw-Hill Professional, May given to those who have five or fewer skin 2003 lesions without detectable bacilli, whereas 9. An evaluation of the S-100 stain in the histological diagnosis of tuberculoid leprosy and other the multibacillary treatment is given to granulomatous dermatoses. Int J Leprosy and Other those who have six or more skin lesions Mycobacterial Diseases. For 10 years we have used treatment by electric cautery to tighten the skin and allow patients to avoid blepharoplasty surgery. This treatment does not replace blepharoplasty in patients with significant infra-orbital fat pads, but it is an excellent option for many patients. We have been utilizing this technique, which involves using an electric cautery to tighten skin, for more than 10 years. The cautery is applied at Figure 1 Figure 3 low intensity, usually at a setting between 1 and 2.