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C H A P T E R 3 6 Drugs Acting on the Renin- Angiotensin-Aldosterone System Laura D buy metoprolol 25mg lowest price atrial fibrillation treatment. The aldosterone antagonist eplerenone has only two indications: hypertension and heart failure; spironolactone is also used to prevent diuretic-induced hypokalemia and treat hyperaldosteronism generic metoprolol 25 mg otc hypertension xray. Aldosterone secretion is enhanced when sodium levels are low and when potassium levels are high cheap metoprolol 12.5mg without a prescription arrhythmia in 5 year old. In atherosclerosis purchase metoprolol cheap online prehypertension while pregnant, it may be responsible for thickening the intimal surface of blood vessels. Because retention of sodium causes water to be retained as well, aldosterone increases blood volume, which causes blood pressure to rise. In addition, aldosterone can activate the sympathetic nervous system and suppress uptake of norepinephrine in the heart, thereby predisposing the heart to dysrhythmias. Also, aldosterone can promote vascular fibrosis (which decreases arterial compliance), and it can disrupt the baroreceptor reflex. These adverse effects appear to be limited to states such as heart failure, in which levels of aldosterone can be extremely high. Breastfeeding Data are lacking regarding effects on the infant when breastfeeding. A 20% decreased risk for new-onset diabetes was seen with candesartan compared with placebo. Renin is produced by juxtaglomerular cells of the kidney and undergoes controlled release into the bloodstream, where it cleaves angiotensinogen into angiotensin I. Release increases in response to a decline in blood pressure, blood volume, plasma sodium content, or renal perfusion pressure. Reduced renal perfusion pressure is an especially important stimulus for renin release and can occur in response to (1) stenosis of the renal arteries, (2) reduced systemic blood pressure, and (3) reduced plasma volume (brought on by dehydration, hemorrhage, or chronic sodium depletion). For the most part, these factors increase renin release through effects exerted locally in the kidney. However, some of these factors may also promote renin release through activation of the sympathetic nervous system. That is, renin secretion is inhibited by elevation of blood pressure, blood volume, and plasma sodium content. Hence, as blood pressure, blood volume, and plasma sodium content increase in response to renin release, further release of renin is suppressed. In this regard, we can view release of renin as being regulated by a classical negative feedback loop. However, when the enzyme is acting on other substrates, we refer to it by different names. In contrast, the system can be a major factor in maintaining blood pressure in the presence of hemorrhage, dehydration, or sodium depletion. Vasoconstriction raises blood pressure by increasing total peripheral resistance; retention of water and sodium raises blood pressure by increasing blood volume. Vasoconstriction occurs within minutes to hours of activating the system and hence can raise blood pressure quickly. In contrast, days, weeks, or even months are required for the kidney to raise blood pressure by increasing blood volume. Aldosterone then acts on renal tubules to promote retention of sodium and water and excretion of potassium. In addition, they are used to prevent adverse cardiovascular events in patients at risk. Their most prominent adverse effects are cough, angioedema, first-dose hypotension, and hyperkalemia. Elevation of bradykinin causes vasodilation (secondary to increased production of prostaglandins and nitric oxide) and can also promote cough and angioedema.

This seems remarkable purchase 12.5 mg metoprolol with visa arrhythmia 1, as the psychological aspects of the procedure are a prominent The decision to visit a surgeon is influenced by the perceived topic of concern for surgeons buy metoprolol without prescription blood pressure medication patch. Some therefore withdraw from difference between individual appearance and what is per- this procedure they perceive as a minefield laden with both the ceived to be the aesthetic norm in the patient’s social environ- technical difficulty of the operation and the imponderability of ment purchase metoprolol 50mg with amex blood pressure medication patch. The timing frequently coincides with a loss of self-esteem the patient’s reaction to its outcome generic 50 mg metoprolol with amex prehypertension nosebleed. The objective of this due to aging but may be unrelated to this in highly motivated “doers” who simply wish to improve their looks. As patient-doctor relationships may turn sour only after frequently an intuitive spontaneous feeling of disliking the the procedure, recognizing these patients before the decision to patient. A psychiatrist condensed the role of instinct into the operate is taken remains a major challenge. To this end, the surgeon should try to during adolescence, and surgeons should be especially alert clarify the answers to four questions. The most fre- iently remembered as the principle of “4Ws”: quent causes for distress are acne and hair loss followed by the 1. What specifically would the patient like the doctor to do for appearance of the nose. Why does the patient want the operation at this particular improved by surgery in 3. That is, do you think about and the patient should get a clear picture of what the surgeon it a lot and wish you could worry about it less? In this process, both patient and surgeon work their time do you spend thinking about it? The patient must also be well informed about general ● What effect has this preoccupation with your appearance had risks of the procedure, individual factors, and the likelihood of on your life? It is wise to discuss the ○ Significantly interfered with your social life, schoolwork, course of action should the result turn out to be unsatisfactory. It is beyond dispute that canons of particular facial proportions ○ Caused you a lot of distress? In contrast, individual anatomy may deviate mark- the relationship of the vestibular floor to the pyriform fossa can edly from generally accepted proportions while still being per- be noted. In this spirit, Sir Francis Bacon found that “there is no excellent beauty that hath not some strangeness in 4. Nasal skin thickness, texture, and elasticity morphometric analysis in favor of paying attention to the need to be carefully evaluated as these parameters have a direct patients’ wishes and a discussion of suitable techniques based effect on both the choice of surgical technique and surgical out- on computer imaging. Fingertips can palpate the size, shape, and firmness of hypo-plastic chin, a receding forehead, or facial asymmetry the structural framework. Special attention should be reserved may affect the surgical plan and should be discussed with the for junctional areas. Standards of facial proportions are never absolute, the position and the strength of the anterior septal angle. Upper and the aim of any rhinoplasty should respect individual physi- borders of the lower lateral cartilages should be located by gen- ognomy, gender, and character irrespective of the preoperative tle elevation of the nasal tip. This technique will The key process of nasal analysis begins by considering the also allow the surgeon to feel the characteristics of the mem- entire face, rather than viewing the nose in isolation. By palpating the nasal spine, For the purposes of clinical assessment, the face is then sim- information is collected about its shape, symmetry, and protru- ply classified as broad, narrow, short, or long. Crucial features of the facial anat- omy include the symmetry and vertical and horizontal propor- Endoscopy provides unparalleled information about anatomy tions of the face, the distance between the eyes, the symmetry and geometry of the nasal cavity. The first step consists of intro- ments to be considered are the fullness and position of the lip ducing a 30-degree, 4-mm-diameter rigid telescope inserted par- and the shape and protrusion of the chin.

Overflow Incontinence: W ith an over distended bladder buy cheap metoprolol 25mg blood pressure chart height and weight, coughing will increase the bladder pressure and eventually lead to dribbling or small loss of urine cheap metoprolol 12.5mg mastercard arrhythmia natural remedies. Wo r k - Up The history 12.5mg metoprolol visa hypertension portal, physical examination metoprolol 100 mg blood pressure chart high, urinalysis, and post void residual are part of the init ial evaluat ion of urinary incont inence. Lifest yle modificat ions include weight loss, diet ary ch anges (less caffein e/ alcoh ol), avoidin g con st ipat ion, an d smoking cessat ion. Note: A combined stress and mixed incontinence is probably the most common type of incontinence encountered; these patients will have symptoms of both stress and urge. Which of the following is the best method to diagnose the etiology of urinary incontinence? Neurological profile of the sacral nerves Match the following sin gle b est t h er ap y ( A-G ) that will m ost likely h elp in the clin i- cal situat ion described (35. P l a c e m e n t o f a n a r t i f i c i a l u r e t h r a l s p h i n c t e r G. She feels as t h ou gh sh e n eeds t o void, but can n ot make it t o the rest room in t ime. She notes uri- nary loss six to seven times a day concurrently with coughing or sneezing. Post operat ively, the pat ient is not ed t o be voiding but “feels like the bladder is still full. Place a Foley catheter and discharge the patient with catheter if second voiding trial fails. This patient likely has a vesicovaginal (between bladder and vagina) fis- tula from the surgery. If the leakage is slow, sometimes a t ampon is placed into the vagin a an d r em oved aft er 3 0 t o 6 0 m in u t es. C o n st an t wet n ess aft er a p elvic operation suggests a fistula, such as vesicovaginal fistula, which is best treated with surgical repair, since it is an anatomic problem. The operation would include excision of the fis- tulous tract which usually may be infected or weakened, and then closure of the opening. O ther common fistulae that may occur after pelvic surgery include ureterovaginal (bet ween ureter and vagina) and rectovaginal fistulas (between rectum and vagina). This patient h as lon g-st an d in g d iabet es m ellit u s, wh ich is a r isk fact or for a neurogenic bladder, leading t o overflow incont inence. T hese pat ient s generally do not feel the urge to void and accumulate large amounts of urine in their bladders. The best therapy for overflow incontinence (neurogenic bladder) is intermittent self-catheterizat ion. N either surgery (indicated for fistula repair), nor Burch urethropexy (indicated for genuine stress incontinence) would be appro- priate for this scenario because it is not an anatomic problem. The medi- cat ion s list ed would also n ot be in dicat ed for n eu r ogen ic blad d er ; h owever, Bet h an ech ol is a com m on ly pr escr ib ed d r u g t o h elp st imu lat e blad d er con - tractions by selectively acting on muscarinic receptors in the bladder muscles in individuals wit h overflow incont inence. This woman’s prominent urge component makes urge incontinence the most likely diagnosis, best treated with anticholinergic medications. Surgery would not be indicat ed in t his situat ion, and in fact, may worsen t he situat ion by furt h er damag- ing nerves and muscles of t he bladder. An art ificial uret h ral sph inct er would not improve the patient’s symptoms because the problem has to do with the detrusor muscle, and not the urethral sphincter. The patient is not having a problem with overflow, so self-catheterization would not be helpful either. The medications listed would not be indicated for this patient because her symp- toms are due to a weakening of the pelvic diaphragm versus a problem with the bladder itself, or muscles of the bladder, as with urge incontinence.

After this procedure generic metoprolol 25 mg line arrhythmia and palpitation, good results with a low revision rate were achieved within the past decades order 100 mg metoprolol visa blood pressure young. This step is followed by elevation of properly not to risk secondary slipping or deflecting metoprolol 12.5mg otc heart attack zip. This may mucoperichondrial flaps and bilateral extramucosal dissection be performed with a single stitch or a figure-of-eight suture of the junction between the dorsal septum and the upper using Vicryl (Ethicon Inc discount 25mg metoprolol mastercard blood pressure names. The septum is separated from the upper lat- 28 are sufficient remaining fibers around the anterior nasal spine. Additional septoco- straight neoseptum of appropriate dimensions, s-30 to 35mm lumellar mattress sutures, anchorage sutures through the nasal along the nasal dorsum and 16 to 20mm along its caudal end. Extended septal batten or whole septum, because often in the area of the osseocartilagi- spreader grafts provide secure refixation in caudal septal nous junction, a long-enough straight part can be found to act replacement graft techniques. Then the dorsum will become the new reconstruction, the septum is best refixated using horizontal anterior border. To create a straight septal plate, finally, redun- U-shaped or running sutures to the upper laterals as well as dant and dislocated cartilage is excised and straight pieces by the above-mentioned premaxilla groove and the bone sutured together. Only in case of instability in scoring, adjusting mattress sutures, or smoothing with a drill. If the K-area does the septum also have to be resuspended to reinforcement is required, smoothly filed pieces of the perpen- 29 the nasal bone. Spreader grafts sutured in place are ideal to stabilize the upper border of the septum and to 7. The straightened new septum is reimplanted between the subperichondrial and sub- At the end of surgery, the septum should stay in the midline periosteal layers and refixed to the upper laterals and the ante- without tension, providing sufficient support to the nasal rior nasal spine. For better needed but usually is not necessary after mattress suturing and drainage of the blood between the mucoperichondrial flaps, a splinting. However, soft packing for 12 to 48 hours reduces small posterior mucosal incision is recommended. In general, the splints are removed at day 4 to 5, in Proper preoperative analysis and classification of the type of complete septal reconstruction at day 10 to 12. As a rule of thumb, slight deviations, single spurs and deformities such as S-shaped and wavelike deviations, the mul- maxillary crests, the septal tilt, and simple C-shaped deform- tiple fractured and preoperated septum, and severe malforma- ities may be mastered endonasally using the swinging door tions such as the cleft nose, the external approach combined technique, scoring incisions, septal batten grafts, septal resec- with complete extracorporeal reconstruction has been found to tions, or caudal replacement grafts. The correction of deflections of the nasal septum with minimum of Clin Laser Med Surg 1997; 15: 123–129 traumatism. Normale und pathologische Anatomie der Nasenhohle und Arch Otolaryngol 1929; 9: 282–292 ihrer pneumatischen Anhange. An operation to repair lateral displacement of the lower border of sep- 1882 tal cartilage. An operation to repair lateral displacement of the lower border of sep- - nasal breathing. Reconstruction of anterior nasal septum: back-to- (Basel) 1958; 20: 115–124 back autogenous ear cartilage graft. Correction of caudal septal deviation: use of a caudal 37: 415–422 septal extension graft. Plast Reconstr Surg 1995; 95: 672–682 10: 152–157 [11] Zachow S, Steinmann A, Hildebrandt T, Weber R, Heppt W. Otolaryngol Head Neck Surg 1999; 120: 1983; 72: 735–736 678–682 60 The Importance of the Nasal Septum in the Deviated Nose 8 The Im portance of the Nasal Septum in the Deviated Nose Jonathan M. Sykes, Ji-Eon Kim, David Shaye, and Armando Boccieri nasal spine of the premaxilla. The structural variations of the nasal secondary to trauma, contributes to deformity.

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