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one should begin with triamcinolone 01% or a stronger corticosteroid then taper to hydrocortisone or another slightly stronger mild corticosteroid (Aclovate, Desonide) It is vital that patients taper corticosteroids and substitute emollients when the dermatitis clears to avoid the side effects of corticosteroids Tapering is also important to avoid rebound flares of the dermatitis that may follow their abrupt cessation Doxepin cream 5% may be used up to four times daily and is best applied simultaneously with the topical corticosteroid Stinging and drowsiness occur in 25% Tacrolimus ointment (Protopic 003% or 01%) and pimecrolimus ointment (Elidel 1%) can be effective in managing atopic dermatitis when applied twice daily Burning on application occurs in about 50% of patients using Protopic and in 10 25% of Elidel users, but it may resolve with continued treatment These medications do not appear to cause skin atrophy, striae, or other topical corticosteroid-associated side effects and are safe for application on the face and even the eyelids The US Food and Drug Administration (FDA) has issued a black box warning for both topical tacrolimus and pimecrolimus due to concerns about the development of T-cell lymphoma The agents should be used sparingly and only when less expensive corticosteroids cannot be used Tacrolimus and pimecrolimus should be avoided in patients at high risk for lymphoma (ie, those with HIV, iatrogenic immunosuppression, prior lymphoma) The treatment of atopic dermatitis is dictated by the stage of the dermatitis 1 Acute weeping lesions Use water or aluminum subacetate solution (Domeboro tablets, one in a pint of cool water) or colloidal oatmeal (Aveeno; dispense one box, and use as directed on box) as soothing or astringent soaks, baths, or wet dressings for 10 30 minutes two to four times daily Lesions on extremities particularly may be bandaged for protection at night Use high-potency corticosteroids after soaking but spare the face and body folds Tacrolimus may not be tolerated at this stage Systemic corticosteroids may be required (see below) 2 Subacute or scaly lesions At this stage, the lesions are dry but still red and pruritic Mid- to high-potency corticosteroids in ointment form should be continued until scaling and elevated skin lesions are cleared and itching is decreased substantially At that point, patients should begin a 2- to 4-week taper from twice-daily to daily to alternate-day dosing with topical corticosteroids to reliance on emollients, with occasional use of corticosteroids on specific itchy areas Instead of tapering the frequency of usage of a more potent corticosteroid, it may be preferable to switch to a low-potency corticosteroid Tacrolimus and pimecrolimus are more expensive alternatives and may be added if corticosteroids cannot be stopped to avoid the complications of long-term topical corticosteroid use 3 Chronic, dry, lichenified lesions Thickened and usually well-demarcated, they are best treated with highpotency to ultra-high-potency corticosteroid ointments Nightly occlusion for 2 6 weeks may enhance the initial.

Example A-56. One solution to Exercise 19-1 (continued)

Present with sudden onset of worst headache of life, may lead rapidly to loss of consciousness; signs of meningeal irritation often present; etiology usually aneurysm or AVM, but 20% have no source identified Most located in the anterior circle of Willis and are typically asymptomatic until subarachnoid bleed occurs; 20% rebleed in first 2 weeks

Prevent further bleeding by clipping aneurysm or coil embolization; nimodipine helps prevent vasospasm; reverse vasospasm by intravenous fluids and induced hypertension after aneurysm has been obliterated, if no other aneurysms are present; angioplasty may also reverse symptomatic vasospasm Surgery indicated if AVM has bled or to prevent further progression of neurologic deficit; other modalities to treat nonoperable AVMs are available at specialized centers

CT reveals bleed, and may reveal the AVM; may be seen by MRI Angiography demonstrates feeding vessels and vascular anatomy

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<Button Style="{StaticResource buttonStyle}" Height="23" HorizontalAlignment="Right" Margin="0,0,37,56" Name="button3" VerticalAlignment="Bottom" Width="75">Button3</Button> <TextBox Style="{StaticResource textboxStyle}" Height="23" Margin="19,0,139,55.48" Name="textBox3" VerticalAlignment="Bottom">TextBox3</TextBox> </Grid> </Window>

1 Obstruction of carotid circulation Occlusion of the ophthalmic artery is probably symptomless in most cases because of the rich orbital collaterals, but its transient embolic obstruction can lead to amaurosis fugax sudden and brief loss of vision in one eye

Occlusion of the anterior cerebral artery distal to its junction with the anterior communicating artery causes weakness and cortical sensory loss in the contralateral leg and sometimes mild weakness of the arm, especially proximally There may be a contralateral grasp reflex, paratonic rigidity,

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