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E. Cobryn, M.B.A., M.B.B.S., M.H.S.

Vice Chair, University of Connecticut School of Medicine

Acinetobacter calcoaceticus, Enterobacter aerogenes, Escherichia coli, Haemophilus influenzae, Haemophilus aegypticus, Klebsiella pneumoniae, Moraxella lacunata, Morganella morganii, Neisseria perflava, Neisseria sicca, Proteus mirabilis, Proteus vulgaris, Pseudomonas aeruginosa. In vitro bacterial studies demonstrate that in some cases bacteria resistant to gentamicin are susceptible to tobramycin. No impairment of fertility was noted in studies of subcutaneous tobramycin in rats at doses of 50 and 100 mg/kg/day (equivalent to human doses of 8 and 16 mg/kg/day, at least 2 orders of magnitude greater than the topical ocular dose). Tamper evidence is provided with a shrink band around the closure and neck area of the bottle. They divide up the segments of the liver: 1 = caudate 2-4 = left lobe 5-8 = right lobe Portal Tract the portal tract (made of up the three structures below) is enveloped by a small amount of fibrous tissue. The abrupt transition between the fibrous tissue and the hepatocytes is the limiting plate. This is important histologically b/c infalmmation extending beyond that limiting plate is important to note. Lobule unit: central /terminal hepatic vein in center with cords of hepatocytes radiating out, extending to the portal triads/ tracts. Bile formed in the hepatocytes flows through hte canalicular spaces back towatrds the portal tract. Zone 1: freshest blood, most O2-rich Zone 3: O2-poor blood, right near central vein. If you see hepatocytes in cords that are thicker than this (1-2 cells), you start thinking about a neoplastic process. Can still see the demarcation where the inflammation ends and the hepatocytes begin. No interface activity like on the right - inflammation is contained with the portal tract. Know specifically because of how it applies to Reyes syndrome and fatty liver of pregnancy. Left: balloon cells and Mallory bodies are the histological hallmark of steatohepatitis. Balloon Cells with Mallory Bodies Acidophil Body (Councilman Body) Hepatocytes form bile. This can occur either within the hepatocytes (L) or within the canalicular spaces (R). Cholestasis plugs of bile within canalicular spaces Intracellular bile accumulation Hepatocellular cholestasis Canalicular cholestasis Patterns of Hepatic Injury Dividing up injury patterns by the cell that is getting destroyed. Serum alkaline phosphatase Serum -glutamyl transpeptidase Serum gamma-glutamyl is quite specific for the biliary system. Hepatocyte Function Secreted proteins (blood) Look at things the liber either produces (albumin) or metabolizes (ammonia). Hemochromatosis Alpha-1-antitrypsin Wilson Disease Metabolic disease (not addressed in this talk) Like glycogen storage disorders - not covered today Viral Hepatitis Viruses that can affect any organ/system, not specific to liver. Lobular injury: inflammation and injury of the hepatocytes Councilman bodies, balloon cells, etc. Chronic (at least 6 months): can still have ongoing active injury (portal, interface, or lobular hepatitis) with scar tissue due to fibrosis within the liver. Hep B infection once chronic is an independent risk factor for the development of hepatocellular carcinoma. With alcohol related injury, the ratio changes as above - this can help distinguish from other types of liver damage. Non-Alcoholic Fatty Liver Disease Very similar histologically to alcoholic fatty liver. Steatohepatitis Progression Big balloon cells Fibrosis (blue) pattern is rather unique. Fibrosis starts surrounding individual cells that are injured; called perisinusoidal or pericellular fibrosis.

They reported that subgingival calculus formation began 6 to 8 years after eruption, continuing to approximately 30 years of age, at which time it leveled off. Teeth with calculus showed a significantly higher rate of attachment loss than teeth without calculus. Subgingival calculus was found to form first on the mandibular incisors and maxillary molars, suggesting that the initial deposits in a supragingival location might have created conditions facilitating subgingival calculus formation. Calcification occurs when this mechanism is disrupted by a number of possible agents. Subsequently, calculus attachment in areas of cemental separation (Moskow, 1969) and by direct contact of calcified matrix to tooth structure (Selvig, 1970) was reported. Intimate adaptation of calculus to cementum mediated by an indistinguishable interface ("calculocementum") was frequently observed. Supragingival calculus was heterogenous, presenting filamentous microorganisms, small needle-shaped crystals, and large ribbon-like crystals (islets of intermicrobial calcification). Bundles/rosettes of large crystals (1 nm to 50 nm long) were associated primarily with the small crystals (versus microorganisms). Only small crystals (< 50 nm) were present in the calculus itself, initially occurring within the microorganisms; a few noncalcified microorganisms were observed. The bacterial cell wall was the last structure calcified in supragingival and subgingival calculus. The author discussed epidemiologic, clinical morphological, and experimental aspects. Salient points of this review are presented below, noting the original authors and publication dates. Schroeder (1969) considered plaque the cause of inflammation and calculus the result of inflammation which in turn promotes chronic inflammation. While studying 200 dental students and 200 dental clinic patients, Alexander (1971) reported a closer match between the distributions of gingival indices and plaque than between gingival indices and calculus. Buckley (1980) examined 300 teenagers and reported a higher correlation between gingival indices and plaque than between gingival indices and calculus. Calculus Toxicity Supragingival calculus is completely permeated by dyes in 24 hours (Baumhammers and Rohrbaugh, 1970). Calculus and cementum from periodontally diseased teeth have induced bone resorption in vitro (Patters, 1982). Calculus and Attachment Loss Lennon and Clerehugh (1984) determined that calculus was the best predictor of attachment loss epidemiologically. Tagge (1975) noted that removal of calculus resulted in statistically greater improvement in probing depths and soft tissue response than oral hygiene alone (22 patients). Chawla (1975) observed that scaling and oral hygiene correlated directly to improvement in clinical health; plaque control alone failed to result in such improvement (1,500 patients). Hughes and Caffesse (1978) found that plaque control had minimal influence on attachment levels and that root instrumentation was the primary contributor to positive gingival changes (15 patients). Cercek (1983) compared brushing and flossing in 7 patients to removal of only subgingival plaque or removal of subgingival plaque and calculus. He observed that removal of subgingival plaque only resulted in little reduction in bleeding scores or improvement in probing attachment levels (neither did supragingival plaque removal by brushing/flossing). Only the removal of both subgingival plaque and calculus resulted in clinical improvement. Ramfjord (1982) found that with professional tooth cleaning every 3 months, the level of oral hygiene was not critical for maintenance. Using loops and fiberoptic lighting, the most apical level of calculus was grooved with a bur. Histologic evaluation of en bloc tissue specimens failed to reveal calculus apical to the groove in any specimen. Mean distance of apical calculus to defect base was significantly greater for 3-wall defects than for 1- and 2-wall defects and increased as intrabony defect depth increased. In most cases, the apical extent of calculus was found at mid-depth of intrabony defects. Calculus and Healing In order to achieve faster healing post-mucoperiosteal flap reflection, instrumentation of the root surface is required. Calculus retained after instrumentation is associated with increased inflammatory infiltrate in the connective tissue.

The brain tumor is the "zebra" but there are grave consequences to missing this diagnosis. It is critical to rule this possibility out before moving forward with other possibilities. When you look at the statistics of these tests, you can see that although the sensitivity is not high, specificity is excellent. Likewise, positive predictive values coupled with the high specificity make these superb diagnostic tests. Should one or more of these tests be positive, a dialogue with the primary care physician would be in order. In addition to cancer, there are several other medical conditions that should be ruled out before proceeding with a lower extremity examination. If you are a middle-aged adult, chances are you have had many headaches over the course of your life span. So a headache may not be a big concern for an adult but it may be a red flag for a three or four year old child. The diagrams below show the anatomic location of the visceral structures and the referral pattern of each struc- Below are the details for six of the 13 tests reviewed. These are simple maneuvers that could be performed in seconds to assess the likelihood of a unilateral brain tumor. Some of the issues that could include the lower extremity could originate from the kidney which refers to the flank. The bladder and colon, as well as the ovaries, uterus, and testicles, refer to the groin. Ruling out an ovarian cyst when an individual presents with groin pain would be important. So we really need to know where these structures are and recognize where they refer to so that we can also rule out visceral issues as part of our initial data gathering. The test involves positioning the client in left sidelying and extending the right hip while stabilizing the lumbar spine. By taking the right hip back into extension, the psoas - a hip flexor - will tug on the adjacent appendix and reproduce the symptoms. Given that the specificity for this test is 95%, it can serve as a strong diagnostic tool. The technique involves pushing down vertically into the gut very slowly, and then releasing quickly. A positive test does not tell you anything about what kind of problem may be present, just that there is a concern. So that may be a piece of information that you store, and then you look further into other areas. If there is any concern about the psoas test being a false positive, the obturator sign could be performed. Press firm and deep into the abdominal region to palpate the pulsation of the aorta. Place a thumb on one-side and an index/middle finger on the other side and measure this distance. When accompanied by back pain with palpation and/ or bruits on auscultation, is reason for significant concern. However, it is important to note sensitivity decreases significantly when abdominal girth exceeds 100cm (39. Abdominal Aorta Palpation the obturator sign is similar to the psoas sign in that it uses the proximity of the obturator internus to the appendix. Since the obturator internus is a hip external rotator, this position will put the muscle on a stretch and incriminate the appendix. Although the testing process parallels that of the psoas sign, there is not any statistical data to support its use.

While citric acid/fibronectin application improved probing depth and probing attachment levels to a statistically significant degree, the difference was clinically insignificant (a matter of 0. Human Studies: No Effect Parodi and Esper (1984) tested the ability of citric acid to promote new attachment and induce bone formation in alveolar defects in humans. Results showed a reduction in probing depth (2 to 3 mm) gain in attachment (1 to 1. They treated 19 patients by mucoperiosteal flaps, debridement, root planing, and citric acid with or without autogenous osseous grafts. They found that osseous grafting did not enhance the results achieved by citric acid conditioning alone and provided results similar to that expected with surgical debridement alone. Marks and Mehta (1986) evaluated citric acid conditioning (pH 1 for 3 minutes) on 3 patients involving 72 teeth with moderate periodontitis. Results at 12 months showed citric acid did not enhance new connective tissue attachment as measured clinically. In a split mouth design, 12 patients had the experimental teeth treated with citric acid pH 0. They showed that both controls and acid-treated teeth demonstrated gain in attachment levels, but there was no difference between them. After removal of the alveolar plate, the surfaces were root planed and treated with citric acid or without. It was determined that reparative dentin formed but did not cause inflammatory reactions in the pulp. On the test side, citric acid was applied to the inner flap for 3 minutes while the control side was treated with saline. They demonstrated no irreversible effects resulted on the exposed soft tissues or underlying alveolar bone at any time point. Nine cats each provided 1 negative and 1 positive control and 2 experimental canine teeth. Positive controls were treated by surgery only while the experimental teeth received surgery with citric acid conditioning. Positive controls showed mild to moderate short-term and mild to no pulpal reactions long-term. Five experimental teeth became abscessed or necrotic, although 4 teeth were relatively non-inflamed. Nine patients had citric acid pH 1 applied locally to the gingiva for 5 to 10 minutes. Citric acid resulted in edema of the prickle cell layer with disarrangement of the tonofilaments and karyolysis of the nucleus. It was suggested that the alterations may contribute to the prevention of the formation of a long junctional epithelium. Citric acid treated teeth reduced both aerobic and anaerobic numbers, while there was no difference in numbers before and after saline treatment in the control teeth. They found that antiformin alone or in combination with citric acid neutralization resulted in endotoxin levels of less than 1 ng/gm, approaching levels found in undiseased roots. Forgas and Gound (1987) compared the effects on darkfield microscopic parameters of root planing alone versus root planing plus antiformin-citric acid application. Both treatments resulted in decreased proportions of spirochetes and motile rods, with no differences between treatments. Five extracted teeth were sectioned longitudinally, and 1 segment was treated with citric acid pH 1 for 3 minutes. Controls showed surface debris and large amounts of bacteria on the retained calculus. Corley and Killoy (1982) studied the stability of citric acid solutions used for root conditioning. A solution of citric acid pH 1 achieved by 61 grams of citric acid crystals in 100 ml of distilled water was tested for the effects of light, time, and air exposure. They were immersed in various concentrations of tetracycline solutions for 5 minutes.

A link to the MedWatch Online Voluntary Reporting Form is shown in an accompanying box. The International Workshop on Meibomian Gland Dysfunction: Report of the subcommittee on anatomy, physiology and pathophysiology of the meibomian gland. Comparative toxicity of preservatives on immortalized corneal and conjunctival epithelial cells. Dry eye syndrome due to botulinum toxin type-A injection: guideline for prevention. The misquoted vanity image, however, may be quite applicable in this day and age, when aesthetics is a growing industry for both women and men. The antiaging and facial rejuvenation sectors of dermatology and eye care are growing rapidly. According to statistics on plastic surgery procedures from the American Society of Plastic Surgeons, there were 15. Because of their youthful reserves, young people do not immediately see the impacts from tanning, junk food, poor sleep and hygiene: the consequences come later. The people now entering this consequence phase are helping to drive the increasing popularity and acceptance of antiaging cosmetic products and procedures. As aesthetic procedures have gained popularity over the recent decades, we have learned that what is good for the skin, our largest organ, is not always friendly to the eyelid. The eyelid protects the ocular surface, which would otherwise be vulnerable as the only mucous membrane exposed during all waking hours to the environment. These have a negative impact on the crucial, specialized meibomian oil glands of the eyelids. As seen with retinoic acid, what is good for the skin may not always be good for the eyes. Lighting changes give the appearance of improved skin tone and fewer undereye wrinkles in the bottom photo. One easy way to compare enhancements with lighting is noting the pupil reflex, if a flash is used there will be a pinpoint of light centrally in the pupil. In the world of cosmetic marketing and advertising, "before" and "after" photos are commonly used to show the benefits of a product. Pixel adjustments of the "before" photo could also be used to make the original look worse, thereby enhancing the delta between the before and after images. If the "after" image has diffuse, multiple light sources, the shadows are filled in, creating the illusion of greater effect. This trick can improve the appearance of nuchal skin laxity, an effect that some firming creams may claim. The "after" photo may then be taken with a lower millimeter lens for a wider field of view along with less detail, creating the illusion of improvement. Combined with diffuse lighting tricks before and after, the effects of a skin care product can be significantly enhanced. Subtle photography color gels can filter certain wavelengths and add to a glowing appearance. Pay close attention to the overall color, looking for cool or warm overtones that may have been leveraged to enhance the illusion of effect. Use of botulinum toxin by teenagers, or "teen toxing," is increasing around the globe. According to the American Society for Aesthetic Plastic Surgery, in 2009 botulinum toxin injections were the fifth most often performed cosmetic procedure for patients 18 years and younger. This raises several questions: Is this young generation of botulinum toxin users more appearance-conscious due to the rise of social media, or are they more prevention-aware and antiaging savvy? First jobs enable more buying power and routine aesthetic enhancements, while media and marketing campaigns further lure these youths into believing that aging prevention is key. Establishing good habits during these years can improve the appearance of the skin for years to come. A lifetime of decreased squinting from sun glare can be achieved through establishing the habit of regular sunglasses use. During the 20s, we should encourage patients to eliminate bad habits such as tanning, smoking, excessive alcohol consumption, and ubiquitous all-nighters. Moreover, just as cigarette smoking has long been known to accelerate aging,11 recent research also shows its negative impact on the ocular surface, with decreased Schirmer test scores and goblet cell density in smokers compared with nonsmoking control subjects.