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Kevin J. Butterfield, DDS, MD, FRCD (C)
The retrospective database review found patients treated either minimally invasively or openly for adolescent idiopathic scoliosis between November 2012 and January 2014 impotence when trying for a baby buy 20mg tadora free shipping. Following matching according to 17 42 Mar Issue Minimally invasive surgery Minimally invasive surgery "markedly reduces" postoperative infection risk 11 L Minimally invasive surgery is generally considered to reduce blood loss and preserve surrounding tissue coffee causes erectile dysfunction buy tadora 20 mg otc, among other benefits erectile dysfunction pills online discount tadora 20mg on-line. There is a dearth in the literature erectile dysfunction hiv purchase tadora 20mg fast delivery, however, on the association between minimally invasive techniques and surgical site infections. Research published in the Asian Spine Journal has found very low rates of postoperative infection following minimally invasive spinal surgery in comparison to open surgery. Hypothetically, it appears that the incidence of surgical site infection should be minimal in minimally invasive surgery compared to open surgery-the reasons being lesser soft tissue dissection, lesser destruction of tissues, lesser exposure of surface area to pathogens etc. One surgery was particularly long, one involved the accidental puncture of the abdomen with a guidewire, and one required the use of a power drill to create tracks for pedicle screws due to tough bone. The authors performed a literature review using a Medline search to find reported rates of infection in open surgery for comparison. Because it was a single-centre trial, the authors note, longer operative times and steep learning curves associated with minimally invasive surgery might lead to different results at different centres, depending on the experience of surgeons. The tiny number of infections in the series, too, means that "a valid conclusion regarding the risk factors cannot be extracted" and "do not represent every situation that could arise in patients with surgical site infections. This makes for a two- to 16-fold increase in postoperative infection in comparison to the results for minimally invasive procedures in the present study. The researchers also used hospital records to work out the financial burden of the direct costs of surgical site infection. She speaks to Spinal News International about her career, her academic work, and the latest developments in the spinal device arena. How did you get into biomedical engineering, and what appealed to you in particular about spine I originally received a biology degree with the intent to go to medical school to become a cardiac surgeon in 1985. During that time, I attended a lecture on future technologies related to prosthetics. This changed my focus to engineering with a goal to enter into developing cutting-edge medical technologies. During my education, I also worked for the Department of Orthopedics at the State University of New York in Syracuse, where my research focused on the effects of osteoporosis on bone mechanics and morphology, as well as studying different stabilisation systems and their effects on spinal biomechanics. These sensors could be incorporated into spinal devices or other medical devices that could provide real-time in vivo information related to local tissue healing or, when used in spinal applications, could provide the status of a fusion. It is encouraging to see that medicine has advanced to a stage where the potential for organ or neural regeneration is not that far off into the future. What do you think has been the biggest development in spinal surgery during your career I was incredibly fortunate to have started my career working under the direction of Dr Hansen Yuan, a worldrenowned spine surgeon and entrepreneur, who was an incredible role model and mentor to me. His extensive knowledge of new technologies and business acumen sparked my enthusiasm in the medical device industry. Obtaining my doctorate in engineering was a personal achievement that opened new and exciting opportunities towards my future career. This significantly broadened my experience with new technologies and escalated my academic career, where I became actively involved with teaching and lecturing at numerous medical and engineering conferences worldwide. I was able to maintain an academic role while pioneering new technological areas and paving the way for new regulatory and testing strategies. I currently serve on editorial boards for a number of medical and engineering journals, and continue to move forward with my work in nanotechnology. The biggest development with respect to treating spinal degeneration has been the total artificial disc, which changed the traditional treatment of fusion for spinal instability. With gaining popularity of 3D-printed technology used to manufacture open structures and scaffolds for tissue incorporation into medical devices, bioprinting is in its early stages of development where human tissue can be printed, including neurons, seeded scaffolds, and eventually entire organ systems. Although this technology is still in its research and development stage, it offers a very promising future for regenerative medicine which stands to significantly change the treatment plan for spinal patients. The most challenging part is ensuring that all of the research studies, testing, and evaluations performed on a new technology prove the device is safe and effective and has been subjected to intense evaluation to avoid unforeseen complications or catastrophic failures upon human use. This is a difficult task, as many potential complications cannot be predicted, modelled, or measured in a clinical study. Therefore, there is a balance to achieve between appropriate evaluation and potential risk. Since it is impossible to mitigate every risk, added tests may be needed to address risks with greater chances of occurring. How has the regulatory approval process changed in your time as a researcher and consultant The regulatory approval process has changed significantly over the past few years. You have been involved extensively with musculoskeletal research, heading two departments at the Cleveland Clinic in your time. Although the majority of my research in the early years was focused towards spinal biomechanics, I had also spent many years studying musculoskeletal injuries and trauma, with a concentration in craniomaxillofacial and traumatic brain injuries. Currently, my two companies create a turn-key approach for the assessment of medical devices from the early stages of development to post-commercialisation, where both regulatory and test strategies, along with clinically relevant testing scenarios are designed and implemented to effectively assess devices for safety and potential high risk situations. I enjoyed those research opportunities where I was involved in the development of early-stage medical technologies originating from military applications. Multiple microsensors that could fit within the eye of a needle were capable of sensing pressures and strains, which are the basic parameters Outside of your own work, what has been the most interesting paper that you have seen in the last 12 months I tend to favour articles that are related to new technologies and materials that focus on tissue incorporation or regeneration, from the nano to macro level. For example, nanotechnology has been used to augment cellular differentiation and organised tissue formation by creating nanostructures or scaffolds that can be seeded with stem cells. Additive manufacturing has provided a vehicle for manufacturing many different types of medical implants that could optimise cellular mechanics at the bone interface with the potential to provide earlier stabilisation, less particulate generation, improved fusion rates. Your work with societies stretches from presenting lectures to chairing committees. The biggest challenges are financial; establishing the necessary funding to bring an idea to market, which include the costs that are needed to ensure the device is functional, durable, surgically safe, and will provide the long-term stabilisation needed to satisfy the specific clinical objective. Establishing the appropriate team to achieve the goal is just as important as the financial and equally as challenging. Of the product developments you have overseen in your work, which have been the most exciting The rapid adoption of new manufacturing techniques for creating innovative orthopaedic and spinal implants that could not be manufactured conventionally has changed implant design considerably. Such fabrication technologies have the potential to change how implants behave in the body. The open architecture created by additive manufacturing for spinal devices could not be produced easily with Societies can offer a community where the healthcare professionals can go to learn about current concepts, strategies, and technologies from their peers. Additionally, they can establish an environment where clinicians, surgeons, scientists, engineers, and industry can work together as a team to innovate novel technologies to address unmet clinical needs. A society not only informs us about strategies and techniques that work, but also works to inform us about the strategies and techniques that do not work, and allows the professional community to have candid, open discussions about surgical techniques, implant characteristics or implementation, successes, and failures. How do motion preservation implants alter the longterm biomechanical environment for the ageing and degenerative spine Will robotics effectively improve surgical outcomes and reduce the complication and revision rate for spinal surgeries, and reduce cost long-term In my opinion, the development of regenerative technologies that are created in the laboratory setting, such as that of bioprinting neurons, and implanted to regenerate and innervate portions of an anatomical structure may be the next big milestone in spine. We all possess different experiences and talents which, when combined, equal success. Go above and beyond what is expected of you and aim to provide true value to the company and your team. Work hard and conscientiously, stay honest and ethical, do not take shortcuts, and work towards an end goal that benefits the team. Early brainstorming sessions with the team can lead to ground-breaking innovations. What advice would you give to someone who was starting their career in biomedical engineering
The three types of botulinus toxin how do erectile dysfunction pills work buy tadora 20 mg on line, A impotence with gabapentin quality 20mg tadora, B erectile dysfunction enlarged prostate proven 20mg tadora, and E erectile dysfunction statistics uk 20 mg tadora with visa, cannot be distinguished by their clinical effects alone, so that the patient should receive the trivalent antiserum as soon as the clinical diagnosis is made. This antitoxin can be obtained from the Centers for Disease Control and Prevention, Atlanta. An initial dose of 10,000 U is given intravenously after intradermal testing for sensitivity to horse serum, followed by daily doses of 50,000 U intramuscularly until improvement begins. Guanidine hydrochloride (50 mg/kg) has been somewhat useful in reversing the weakness of limb and extraocular muscles. Antitoxin and guanidine probably change the course of the illness relatively little, and recovery, in the final analysis, depends on the effectiveness of respiratory care, maintenance of fluid and electrolyte balance, prevention of infection, and so on. The skilled injection of small quantities of botulinus toxin into a muscle will weaken or paralyze it for weeks to months. Advantage is taken of this phenomenon in the treatment of the localized dystonias (page 93). Chronic overdosage of the drug is the usual cause of ergotism; acute overdosage in the postpartum state or in the treatment of migraine may cause an alarming rise in blood pressure. Two types of ergotism are recognized: gangrenous, due to a vasospastic, occlusive process in the small arteries of the extremities, and convulsive, or neurogenic ergotism. The latter is characterized by fasciculations, myoclonus, and spasms of muscles, followed by seizures. In nonfatal cases, a tabes-like neurologic syndrome may develop, with loss of knee and ankle jerks, ataxia, and impairment of deep and superficial sensation. The pathologic changes are said to consist of degeneration of the posterior columns, dorsal roots, and peripheral nerves, but they have been poorly described. The relation of these changes to ergot poisoning is not clear, since most of the cases have occurred in areas where malnutrition was endemic. Buckthorn Poisoning A rapidly progressive and sometimes fatal paralysis follows the ingestion of the small fruit of the buckthorn shrub that is indigenous to northern Mexico and the neighboring southwestern parts of the United States. The responsible toxin causes a predominantly motor polyneuropathy, probably of axonal type. Neurotoxin Fish Poisoning (Ciguatera) Ingestion of marine toxins that block neural sodium channels is a common form of poisoning throughout coastal areas and islands of the world. It results from eating fish that have fed on toxin-containing microscopic dinoflagelates. Reef fish and shellfish are exposed to high concentrations of these organisms during periodic upswings in the population of the dinoflagelates. Although the toxins differ (tetrodotoxin- pufferfish; ciguatoxin- snails; saxitoxin and brevitoxin- shellfish), the neurologic and gastrointestinal symptoms that follow the ingestion of poisoned fish are similar. The initial symptoms are diarrhea, vomiting, or abdominal cramps coming on minutes to hours after the ingestion. These are followed by paresthesias that begin periorally and then involve the limbs distally. In pufferfish poisoning and in advanced stages of poisoning from other fish, weakness occurs, and there have been a few reports of coma and of respiratory failure. The recognition of this type of fish poisoning is straightforward in endemic areas, in some of which there is a seasonal clustering of cases. In tourists returning home from endemic areas or in persons consuming imported fish, the illness may be mistaken for the Guillain-Barre syndrome. Supportive treatment is all that is required, but treatment with intravenous mannitol is said to hasten recovery. Pearn reviews the biochemistry and physiologic and clinical effects of the various marine toxins and points out a form of chronic intoxication unknown to us but apparently endemic in certain island communities. The problem of distinguishing this syndrome from depression is acknowledged by the author and the cases on which we have consulted locally almost always fall into the psychiatric category. Lathyrism Lathyrism is a neurologic syndrome characterized by the relatively acute onset of pain, paresthesias, and weakness in the lower extremities, progressing to a permanent spastic paraplegia. It is a serious medical problem in India and in some North African countries and is probably due to a toxin contained in the chickling vetch, Lathyrus, a legume that is consumed in excess quantities during periods of famine. Mushroom Poisoning the gathering of wild mushrooms, a popular pastime in late summer and early fall, always carries with it the danger of poisoning. Most of them cause only transient gastrointestinal symptoms, but some elaborate toxins that can be fatal. The most important of these toxins are the cyclopeptides, which are contained in several species of Amanita phalloides and muscaria and account for more than 90 percent of fatal mushroom poisonings. Symptoms of poisoning with Amanita usually appear between 10 and 14 h after ingestion and consist of nausea, vomiting, colicky pain, and diarrhea, followed by irritability, restlessness, ataxia, hallucinations, convulsions, and coma. Other important toxins are methylhydrazine (contained in the cyromitra species) and muscarine (inocybe and clitocybe species). The former gives rise to a clinical picture much like that caused by the cyclopeptides. The symptoms of muscarine poisoning, which appear within 30 to 60 min of ingestion, are essentially those of parasympathetic stimulation- miosis, lacrimation, salivation, nausea, vomiting, diarrhea, perspiration, bradycardia, and hypotension. If vomiting has not occurred, it should be induced with ipecac, following which activated charcoal should be administered orally in order to bind what toxin remains in the gastrointestinal tract. A local poison control center may help identify the poisonous mushroom and its toxin. Even more important, the gathering and ingestion of field varieties Venoms, Bites, and Stings these are relatively rare but nonetheless important causes of mortality in the United States. The venoms of certain species of snakes, lizards, spiders (especially the black widow spider, page 1280), and scorpions contain neurotoxins that may cause a fatal depression of respiration and curare-like paralysis of neuromuscular transmission. Others (rattlesnakes, water moccasin snakes) cause tissue necrosis and circulatory collapse. The serious effects of Hymenoptera stings (bees, wasps, hornets, and fire ants) are due mainly to hypersensitivity and anaphylaxis. Several instances of cerebral or myocardial infarction have been reported after bee and wasp stings (Crawley et al). Tick Paralysis this rare condition is the result of a toxin secreted by the gravid tick. In Canada and the northwestern United States, the wood tick Dermacentor andersoni is mainly responsible; in the southeastern United States it is Dermacentor variabilis, a dog tick (the tick in Australia is the Ixodes holocyclus), but various other ticks may occasionally have the same effect. The illness is more common and is generally more severe in cases on the Australian Continent than it is in North America. Most cases occur in children because their small body mass renders them susceptible to the effects of relatively small amounts of the toxin. The illness arises almost exclusively in the spring, when the mature gravid ticks are most plentiful. Clinical manifestations require that the tick be attached to the skin for several days. The neurotoxin causes a generalized, flaccid, areflexic paralysis, appearing over 1 or 2 days thereby mimicking the GuillainBarre syndrome. External ophthalmoplegia, which occurred in 5 of the 6 children described by Grattan-Smith et al, is exceptional judging by other reports; internal ophthalmoplegia and pharyngeal weakness are also known to occur, and while not typical, raise the possibility of botulism or diphtheria. Prominent ptosis and neck weakness may also raise the question of a neuromuscular process, but repetitive stimulation testing is normal or evokes only a slight decrement or increment in some cases. The ticks tend to attach to the hairlines or in the matted hair of the scalp, neck, and pubis, where a careful search will reveal them (for which reason nurses and electroencephalography technicians often are most likely to find them; see Felz et al). The diagnosis is much in the awareness of clinicians in endemic areas during the tick season, for they are gratified with rapid and dramatic improvement when the tick is removed. The paralysis is reported to become transiently worse after tick removal in some of the Australian cases. From a neurologic point of view, the frequent disorder that follows tick bite is what has come to be known as Lyme disease- so named for the Connecticut community in which it was discovered. Lead Poisoning in Children In the United States, this disease has been identified most often in 1- to 3-year-old children who inhabit urban slum areas where old, deteriorated housing prevails. The development of an acute encephalopathy is the most serious complication, resulting in death in 5 to 20 percent of cases and in permanent neurologic and mental deficits in more than 25 percent of survivors.
Modeling simulations (computational fluid dynamics) in rats of specific air flows to these tissues indicate olfactory tissues to be specifically sensitive to the effects of H2S erectile dysfunction medication otc buy tadora 20mg mastercard, despite higher regional flow to the respiratory epithelium (Moulin et al erectile dysfunction medication nhs cheap tadora 20mg on line. As discussed above erectile dysfunction 25 buy tadora 20 mg low price, these simulations imply that human olfactory tissues could also be exposed to inhaled H2S erectile dysfunction japan order tadora 20mg, and, as no compelling reason exists to suspect that human olfactory tissue would react any differently to the irritant properties of H2S (the suspected mechanism of damage), it is reasonable to imply that similar effects would be observed in humans. General Question: Do the confidence statements and weight-of-evidence statements present a clear rationale and accurately reflect the utility of the studies chosen, the relevancy of effects to humans, and the comprehensiveness of the data base Do these statements make sufficiently apparent all of the underlying assumptions and limitations of these assessments It was indicated that it was unclear why there was low confidence in the RfC when the confidence in the principal study and data base was medium. Response: the confidence statement was corrected such that the overall confidence in the RfC reflected that of the data base, i. Specific Question: Should the reproductive toxicity of hydrogen sulfide, as seen in the Dorman et al. Comment: Only one reviewer responded this question, indicating that this question was unanswerable as the effect seen on testicular tubules in rats was not clearly adverse and not confirmed in another species. Specific Question: Can you reconcile the controversy over whether hydrogen sulfide affects the brain directly with H2S-induced brain damage due to cytochrome oxidase enzyme inhibition causing morbidity and mortality (Warenycia et al. Comment: One reviewer indicated that the cytochrome oxidase hypothesis and the overall weight of scientific evidence indicate that the instantaneous collapse seen upon exposure to 7501,000 ppm is a result of H2S directly on the brain. There must be an exposure to H2S lasting for a minimum of about 5 minutes during a period of unconsciousness before hypoxic brain damage occurs. There is no reliable evidence that intermittent exposure to levels of H2S below 1 or 2 ppm constitutes a danger to physical health. Response: this effect progression was more clearly expounded upon in the text of the Toxicological Review. The increased emphasis placed in the assessment on the role of cytochrome oxidase in the progression of toxicity, and the advancement of the concept that such an alteration. Meningiomas commonly remain asymptomatic throughout life and may be discovered only during autopsy (39,50). With the advent of advanced neuroimaging, many asymptomatic meningiomas are identified in persons being studied for other reasons (51,52). The characteristic gross appearance is a globular, solid growth firmly attached to the inner surface of the dura, producing an excavation of the underlying neural tissue. A, Large parasagittal meningioma has compressed the right frontal lobe and has displaced the frontal portion of the left hemisphere away from the midline. B, this small meningioma of the right frontal region was an incidental finding at autopsy. The tumor has compressed and excavated but not invaded the portion of the brain adjacent to it. C, Coronal section through the brain of a patient with a sphenoid ridge meningioma. The tumor clearly compresses but does not invade the right frontal and temporal lobes. Conspicuous whorl formations of elongated and crescent-shaped meningioma cells are present. Transitional meningiomas have two distinctive cell populations: the plump, polygonal cells observed in syncytial meningiomas and the spindle-shaped cells tightly wrapped around each other to form a whorl. In tumors with extensive whorl formation, psammoma bodies are usually present. Transitional meningiomas that contain extensive psammoma bodies are also called psammomatous meningiomas. Fibroblastic meningiomas are composed of interlacing bundles of spindle-shaped cells containing conspicuous fibroglial fibrils. These tumors contain some whorls, although they are less obvious and more poorly formed than those observed in transitional meningiomas. A distinctive feature of fibroblastic meningiomas is the extensive development of reticulin and collagen fibers between individual cells, producing a tough, ``fibrous' structure. Angioblastic meningiomas are characterized by extensive blood vessels that resemble capillaries in size and structure. These cells do not form the cellular whorls characteristic of transitional (and to a lesser extent fibroblastic) meningiomas. The two most common variants of angio- the cut surface of a meningioma may have a reddish or brown discoloration from hemorrhage within the tumor. In other cases, particularly in infants and young children, there is a large cyst located adjacent to the tumor (27,56,58,59). Tumors with extensive hemorrhage, cyst formation, or advanced mucoid or fatty degeneration usually have a soft, spongy consistency. Still others contain extensive areas of calcification and are ``gritty' to palpation. Highly vascularized tumors may bleed extensively from fresh-cut surfaces, whereas less vascularized tumors bleed almost not at all. A macroscopic variant of the typical meningioma is the meningioma-en-plaque, which, as its name suggests, is not greatly raised above the level of the dura mater but invades the adjacent bone without producing hyperostosis initially. There are five major microscopic subtypes of meningiomas: syncytial, transitional, fibroblastic, angioblastic, and malignant (60). Syncytial meningiomas lack a boundary between neighboring cells when examined under the light microscope. The highly elongated meningioma cells resemble fibroblasts and form closely interlacing bundles. We agree with those who believe that there is a separate tumor called a hemangiopericytoma that is composed of pericytes and is embryologically, clinically, and morphologically different from the angioblastic meningioma. Clinically aggressive meningiomas tend to have a papillary configuration, increased cellularity, and areas of focal necrosis. As might be expected, meningiomas that are histologically malignant recur more often and sooner after surgery than do meningiomas that are histologically benign, even when postoperative radiotherapy is used (69,70). However, histologically ``benign' meningiomas may also grow rapidly, become locally invasive, and even metastasize. Thus, the criteria for malignancy are more commonly based on their biologic behavior (67). When there is histologic evidence of local invasion, the tumor is considered ``malignant. Most often, dissemination is associated with histologic features of malignancy in a previously resected primary tumor (21,68). Certain deletions (1p, 6q, 10p, 10q, 14q, and 18q) have been associated with higher-grade meningiomas and with progression or recurrence. It has subsequently become clear that meningiomas frequently enlarge or become symptomatic during pregnancy and during the luteal phase of the menstrual cycle (91,92). There is no evidence, however, that meningiomas present more often during pregnancy (93,94). These findings suggest that at least some meningiomas are under hormonal influence. Although the percentage of meningiomas with estrogen and progesterone receptors varies considerably among studies (possibly relating to the use of preoperative glucocorticoid therapy), it is clear that such receptors are present in a substantial number of meningiomas (108,120).
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