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Surgery Surgical treatment of male balding involves the redistribution of terminal hair to cover balding scalp; the number of terminal hair follicles on the scalp remains the same discount advair diskus express asthma definition x-ray. In most cases this means transplanting hair follicles from the occipital scalp to the balding areas proven 500mcg advair diskus asthma bronchitis definition. Other techniques cheap advair diskus online amex asthma symptoms at night, such as excising the balding skin (scalp reduction) and rotational flaps are now less widely used buy genuine cialis extra dosage line. Surgical treatment can achieve very satisfactory results but careful patient selection and surgical skill allied to the aesthetics of scalp hair growth are essential buy zithromax australia. A detailed review of the indications and techniques of hair surgery is beyond the scope of this article generic zenegra 100 mg online. However, key considerations include the following (57): There should be an adequate donor area, i. Surgery in young men may result in misplaced hairlines or an unnatural appearance 20–30 years later as balding progresses. Correction of established frontal hair loss is more effective than vertex balding which tends to progress with time. In Caucasians, fair hair gives a more natural appearance than dark hair (which exaggerates the contrast with the color of scalp skin). Less common problems include infection, post-operative bleeding, scarring, and arterio-venous fis- tula formation. Cosmesis Hairstyling is perhaps the simplest approach to modifying the cosmetic impact of male bald- ing. Currently fashionable short hair styles are particularly effective in minimizing the contrast between balding and non-balding regions of the scalp. While these give an instant result, a natural appearance demands skilled professional input. For those who are keen to be treated there are two medical options: minoxidil solution and antiandrogens. In both cases it should be stressed that treatment will, at best, produce only a modest increase in hair density and that it is not possible to fully reverse hair loss. Furthermore, in those who respond, treatment has to be continued to maintain the response. As in men, surgery is the only method capable of restoring the appearance in the presence of severe hair loss. Minoxidil Minoxidil solution 2% is licensed for the treatment of female androgenetic alopecia in most countries. Clinical trials in the early 1990s using hair counts as a primary endpoint reported a mean increase in hair growth of 15–33% in the minoxidil-treated groups compared with 9–14% in the vehicle control groups (58–60). In the investigator and subject assessments minoxidil was superior to the vehicle, but about 40% of subjects appeared not to respond to minoxidil (58,60). A more recent trial comparing 5% and 2% minoxidil solu- tion found increases of 18% and 14% respectively in mean non-vellus hair counts after 48 weeks of treatment, compared to a 7% increase in the placebo group.

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Nonscombroid fish buy advair diskus 100mcg otc asthma treatment usa, such as mahi-mahi (Coryphaena hippurus) buy advair diskus discount asthma kidshealth, and bluefish (Pomatomus saltatrix) cheap 250mcg advair diskus with amex asthma symptoms from anxiety, are also associated with illness cheap suhagra 100mg on-line. Risks appear to be greatest for fish imported from tropical or semitropical areas and fish caught by recreational or artisanal fishermen buy discount januvia 100mg online, who may lack appropriate storage facilities for large fish buy doxycycline without prescription. Adequate and rapid refrigeration, with evisceration and removal of the gills in a sanitary manner prevents this spoilage. In severe cases, patients may also become hypotensive, with a paradoxical bradycardia. Neurological symptoms, including pain and weakness in the lower extremities and circumoral and peripheral paresthaesias, may occur at the same time as the acute symptoms or follow 1–2 days later; they may persist for weeks or months. Symptoms such as temperature reversal (ice cream tastes hot, hot coffee seems cold) and “aching teeth” are frequently reported. In very severe cases neurological symptoms may progress to coma and respiratory arrest within the first 24 hours of illness. Most patients recover completely within a few weeks; intermittent recrudescence of symptoms can occur over a period of months to years. This syndrome is caused by the presence in the fish of toxins elaborated by the dinoflagellate Gambierdiscus toxicus and algae growing on under- water reefs. Fish eating the algae become toxic, and the effect is magnified through the food chain so that large predatory fish become the most toxic; this occurs worldwide in tropical areas. Ciguatera is a significant cause of morbidity where consumption of reef fish is common—Australia, the Caribbean, southern Florida, Hawaii and the South Pacific. Incidence has been estimated at 500-odd cases/100 000 population/year in the South Pacific, with rates 50 times higher reported for some island groups. The consumption of large predatory fish should be avoided, especially in the reef area, particularly the barracuda. Where assays for toxic fish are available, screening all large “high-risk” fish before consumption can reduce risk. The occurrence of toxic fish is sporadic and not all fish of a given species or from a given locale will be toxic. Intravenous infusion of mannitol (1 gram/kg of a 20% solution over 45 minutes) may have a dramatic effect on acute symptoms of ciguatera fish poisoning, particularly in severe cases, and may be lifesaving in severe cases that have progressed to coma. In severe cases, ataxia, dysphonia, dysphagia and muscle paralysis with respiratory arrest and death may occur within 12 hours. Symptoms usually resolve completely within hours to days after shellfish ingestion. This syndrome is caused by the presence in shellfish of saxitoxins and gonyautoxins produced by Alexandrium species and other dinoflagel- lates. Concentration of these toxins occurs during massive algal blooms known as “red tides” but also in the absence of recognizable algal bloom.

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