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Healthy hair and skin care


Healthy hair and skin care

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You guys asked for it. Here it is. So I better see lots of comment. If you got question ask away!!! Yes I tried to cut alot of things out from this video to fit in the make up too but it just won’t work.

Hair is a protein filament that grows through the epidermis from follicles deep within the dermis. The fine, soft hair found on many nonhuman mammals is typically called fur; wool is the characteristically curly hair found on sheep and goats. Found exclusively in mammals, hair is one of the defining characteristics of the mammalian class. Although other non-mammals, especially insects, show filamentous outgrowths, these are not considered “hair” in the scientific sense. So-called “hairs” (trichomes) are also found on plants. The projections on arthropods such as insects and spiders are actually insect bristles, composed of a polysaccharide called chitin. There are varieties of cats, dogs, and mice bred to have little or no visible fur. In some species, hair is absent at certain stages of life. The main component of hair fiber is keratin.

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Why Patients Aren’t Getting the Shingles Vaccine

Four years ago at age 78, R., a retired professional known as much for her small-town Minnesotan resilience as her commitment to public service, developed a fleeting rash over her left chest. The rash, which turned out to be shingles, or herpes zoster, was hardly noticeable.

But the complications were unforgettable.

For close to a year afterward, R. wrestled with the searing and relentless pain in the area where the rash had been. “It was ghastly, the worst possible pain anyone could have,” R. said recently, recalling the sleepless nights and fruitless search for relief. “I’ve had babies and that hurts a lot, but at least it goes away. This pain never let up. I felt like I was losing my mind for just a few minutes of peace.”

Shingles and its painful complication, called postherpetic neuralgia, result from reactivation of the chicken pox virus, which remains in the body after a childhood bout and is usually dormant in the adult. Up to a third of all adults who have had chicken pox will eventually develop one or both of these conditions, becoming debilitated for anywhere from a week to several years. That percentage translates into about one million Americans affected each year, with older adults, whose immune systems are less robust, being most vulnerable. Once the rash and its painful sequel appear, treatment options are limited at best and carry their own set of complications.

While the search for relief costs Americans over $500 million each year, the worst news until recently has been that shingles and its painful complication could happen to any one of us. There were no preventive measures available.

But in 2006, the Food and Drug Administration approved a new vaccine against shingles. Clinical trials on the vaccine revealed that it could, with relatively few side effects, reduce the risk of developing shingles by more than half and the risk of post-herpetic neuralgia by over two-thirds. In 2008, a national panel of experts on immunizations at the Centers for Disease Control and Prevention went on to recommend the vaccine to all adults age 60 and older.

At the time, the shingles vaccine seemed to embody the best of medicine, both old school and new. Its advent was contemporary medicine’s elegant response to a once intractable, age-old problem. It didn’t necessarily put an end to the spread of disease, in this case chicken pox; but it dramatically reduced the burden of illness for the affected individual. And, most notably, its utter simplicity was a metaphoric shot-in-the-arm for old-fashioned doctoring values. Among the increasingly complex and convoluted suggestions for health care reform that were brewing at that moment, here was a powerful intervention that relied on only three things: a needle, a syringe and a patient-doctor relationship rooted in promoting wellness.


In the two years since the vaccine became available, fewer than 10 percent of all eligible patients have received it. Despite the best intentions of patients and doctors (and no shortage of needles and syringes), the shingles vaccine has failed to take hold, in large part because of the most modern of obstacles. What should have been a widely successful and simple wellness intervention between doctors and their patients became a 21st century Rube Goldberg-esque nightmare.

Last month in The Annals of Internal Medicine, researchers from the University of Colorado in Denver and the C.D.C. surveyed almost 600 primary care physicians and found that fewer than half strongly recommended the shingles vaccine. Doctors were not worried about safety — a report in the same issue of the journal confirmed that the vaccine has few side effects; rather, they were concerned about patient cost.

Although only one dose is required, the vaccination costs $160 to $195 per dose, 10 times more than other commonly prescribed adult vaccines; and insurance carriers vary in the amount they will cover. Thus, while the overwhelming majority of doctors in the study did not hesitate to strongly recommend immunizations against influenza and pneumonia, they could not do the same with the shingles vaccine.

“It’s just a shot, not a pap smear or a colonoscopy,” said Dr. Laura P. Hurley, lead author and assistant professor of medicine at the University of Colorado in Denver. “But the fact is that it is an expensive burden for all patients, even those with private insurance and Medicare because it is not always fully reimbursed.”

Moreover, many private insurers require patients to pay out of pocket first and apply for reimbursement afterward. And because the shingles vaccine is the only vaccine more commonly given to seniors that has been treated as a prescription drug, eligible Medicare patients must also first pay out of pocket then submit the necessary paperwork in order to receive the vaccine in their doctor’s office. It’s a complicated reimbursement process that stands in stark contrast to the automatic, seamless and fully covered one that Medicare has for flu and pneumonia vaccines.

Despite this payment maze, some physicians have tried to stock and administer the vaccine in their offices; many, however, eventually stop because they can no longer afford to provide the immunizations. “If you have one out of 10 people who doesn’t pay for the vaccine, your office loses money,” said Dr. Allan Crimm, the managing partner of Ninth Street Internal Medicine, a primary care practice in Philadelphia. Over time, Dr. Crimm’s practice lost thousands of dollars on the shingles vaccine. “It’s indicative of how there are perverse incentives that make it difficult to accomplish what everybody agrees should happen.”

Even bypassing direct reimbursement is fraught with complications for doctors and patients. A third of the physicians surveyed in the University of Colorado study resorted to “brown bagging,” a term more frequently used to describe insurers who have patients carry chemotherapy drugs from a cheaper supplier to their oncologists’ offices. In the case of the shingles vaccine, the study doctors began writing prescriptions for patients to pick up the vaccine at the pharmacy and then return to have it administered in their offices. However, the shingles vaccine must be frozen until a few minutes before administration, and a transit time greater than 30 minutes between office and pharmacy can diminish the vaccine’s effectiveness.

Dr. Crimm and the physicians in his office finally resorted to what another third of the physicians in the study did: they gave patients prescriptions to have the vaccine administered at pharmacies that offered immunization clinics. But when faced with the added hassles of taking additional time off from work and making a separate trip to the pharmacy, not all patients followed through. “Probably about 60 percent of our patients finally did get the vaccine at the pharmacy,” Dr. Crimm estimated. “This is as opposed to 98 percent of our patients getting the pneumonia and influenza vaccines, immunizations where they just have to go down the hall because we stock it, roll up their sleeves then walk out the door.”

With all of these barriers, it comes as no surprise that in the end only 2 percent to 7 percent of patients are immunized against shingles. “There’s just so much that primary care practices must take care of with chronic diseases like obesity and diabetes and heart disease,” Dr. Hurley noted. “If a treatment isn’t easy to administer, then sometimes it just falls to the bottom of the list of things for people to do.”

“Shingles vaccination has become a disparity issue,” Dr. Hurley added. “It’s great that this vaccine was developed and could potentially prevent a very severe disease. But we have to have a reimbursement process that coincides with these interventions. Just making these vaccines doesn’t mean that they will have a public health impact.”

Feet surgery


Feet surgery

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The podiatric surgeon is taught to approach foot surgery by keeping the knowledge of normal foot function and biomechanics in mind. Because of the weightbearing nature of the foot, surgical procedures must be designed to be as stable as possible to withstand the forces of everyday standing and walking. Care is taken to understand the cause of the problem so as to provide a long-lasting cure, when possible. Greater than 99% of podiatric surgery is done in an outpatient setting such as a hospital outpatient department, a freestanding surgery center or in the podiatry office. Most procedures allow for immediate walking with a surgical sandal. Some procedures may require the use of a cane, crutches, or a cast. Specific surgical treatments for many common (and some less common) foot conditions will be discussed.

Flat Feet (Pes Planus)

Surgery for flat feet is generally reserved for the most symptomatic cases. Orthotics are often the first line course of treatment. Many people have what are referred to as “Flat Feet” but are relatively asymptomatic. Flat feet may result in significant foot pain and deformity because of excessive pronation which causes joint instability. Flat foot procedures are designed to provide for a more stable foot which pronates less. Most flat foot surgery is performed on patients in the adolescent age group. There are a large variety of specific surgical procedures that may be used. They may be grouped according to the region of the foot that is treated. Often, 2 or 3 procedures may be performed together from the different groups.

Rearfoot osteotomies
These are procedures which are designed to change the position of the heel into an inverted or supinated position (the opposite of everted and pronated which are found in flat feet.) An osteotomy is a surgical cut in the bone. Often, a wedge of bone is removed to change the angle of the heel bone (calcaneus).  Other procedures are transpositional and involve sliding of one part of the bone along the other part of the bone. (E.g. the Koutsogianis procedure). Other procedures involve adding a bone graft and opening the wedge to change the angle of the calcaneus.( E.g. the Evans Procedure). These osteotomies are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for several weeks.

Medial column stabilizations
These procedures involve fusing two or more of the bones along the medial side (inner side) of the foot. Common fusion sites are the navicular and medial cuneiform.  These bones have often dropped in a flat foot and fusing them provides more stability. These osteotomies are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for several weeks.

Tendon transfers
Sometimes the insertion sites of tendons are detached and then reattached to bones at different locations. The result is a dynamic stabilization. Repositioning of the tendons allows the muscles that pull them to exert their force in a more beneficial way to help support the arch. The Young tenosuspension procedure reattaches the Tibialis Anterior tendon to a better position beneath the medial arch where it can pull up on the arch to support it.

Tendon lengthening
Often, the Achilles tendon is tight and is a major deforming force contributing to flat foot conditions. A condition associated with a tight Achilles tendon is known as equinus. An Achilles tendon lengthening procedure is often effective at reducing this deforming force. The calf is made up of 2 gastrocnemius muscle bellies as well as the soleus muscle. The Achilles tendon attaches to all three. An Achilles tendon lengthening lengthens the whole group together. Sometimes, the gastrocnemius muscles are tight while the soleus is not. In this case, a gastrocnemius recession can be performed to lengthen only the gastrocnemius while leaving the soleus alone.

These are procedures in which a peg made of plastic or titanium is placed in front of a bone to limit its motion. A common location for placement of such a device is the Sinus Tarsi which is a cone-shaped space between the talus and calcaneus bones. The peg helps to limit pronation. This is often just a temporary measure with the peg left in for a few years and then removed.

An arthrodesis is a fusion of two bones. In addition to the medial column stabilization fusions discussed above, rearfoot bones may also be fused. Rearfoot fusions are generally reserved for the most severely deformed, arthritic and painful feet . A Triple Arthrodesis is a fusion of the Talo-calcaneal, Talo-navicular and Calcaneo-cuboid joints. This is one of the most complex foot surgeries performed since all three joints must be aligned and fused properly to achieve a satisfactory result. In addition, because motion in the rearfoot is eliminated, the ankle joint and other joints in the foot may be forced into compensating to provide additional motion which could result in future symptoms in those places. These fusions are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for two or three months.

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