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DRUG THERAPIES FOR HEALTHY BONES: RALOXIFENE (EVISTA)

The newest pharmaceutical option for protecting bone density is raloxifene (brand name Evista). Raloxifene is a selective estrogen receptor modulator (SERM), which, simply stated, means it has a chemical structure similar to estrogen and attaches itself to molecules in the body where estrogen would otherwise attach. It prevents bone loss by reducing breakdown of bone much the way estrogen replacement therapy does. Postmenopausal women can expect about a 3 percent increase in bone density in the first year of taking raloxifene and 1 to 2 percent per year after that. This brings a 40 to 50 percent reduction of risk of fracture in the spine. Less than 60 percent of women will see increases in bone density with raloxifene, a markedly lower response rate than with the options described earlier, including estrogen. Raloxifene is sometimes given with a progesterone, which might improve your chances of benefiting, as well as the magnitude of your results, though there is no hard evidence of that yet.
Since raloxifene blocks estrogen, it is the best choice for postmenopausal women who can’t take estrogen, especially those fearing an increase in breast cancer risk. It is not an option for men. Although it isn’t quite as effective as other prescription options in protecting bone at the hip, and is only about half as effective in the spine, it doesn’t increase the risk of uterine cancer (as estrogen does) and may actually protect against breast cancer. (Raloxifene is very similar to tamoxifen, which has gotten a lot of press as preventing breast cancer.) It doesn’t cause breast soreness or uterine bleeding, as estrogen can.
If you can take estrogen but are hesitant to, and are wondering if this is a better alternative, note that raloxifene does not offer some of the benefits that estrogen does. Raloxifene’s effect on the heart is still unclear. Though it appears to lower cholesterol levels, it is unknown as yet whether that translates into protection against heart disease and heart attacks equivalent to estrogen’s. Raloxifene does not relieve menopausal symptoms, and can even cause or increase hot flashes. No studies have yet been completed on raloxifene’s effect on colon cancer or Alzheimer’s disease, but estrogen is known to offer protection against both. Finally, raloxifene has one of the same potential side effects as estrogen: dangerous blood clots.
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MANAGEMENT OF THE SIDE EFFECTS OF RADIATION THERAPY IN CHILDREN EARLY EFFECTS

A. Nutritional support
Nutritional support during radiation therapy is vital for the prevention of cachexia, immune compromise, and inability to repair normal tissue damage.
1. Nutritional status needs to be assessed initially.
a. Weight loss probably indicates negative nitrogen balance, which must be corrected.
b. Counsel the patient and family regarding unusual or idiosyncratic dietary habits, to assure a nutritionally complete diet.
Caloric need duri ng radiation therapy is approximately 11096 of baseline.
An enteral diet is preferable to a parenteral diet.
a. Oral diet modifications may be necessary.
i. Taste may change secondary to the tumor or to treatment, which may alter diet.
ii. If the mucosa of the upper gastrointestinal tract is being irradiated, a soft, bland diet may be required (no spicy, acidic, or hot or cold food or drink).
iii. Standard oral supplements must be used if caloric requirements cannot be met otherwise (e.g., Sustacal, Ensure, or Carnation Instant Breakfast).
b. Nasogastric tube feeding is probably required if 1096 weight loss occurs during treatment.
4. Intravenous hyperalimentation is indicated if the patient is unable to tolerate oral or nasogastric feeding.
B. Management of hem atologic and immunologic toxicity Radiation therapy of any part of the body can suppress blood counts, particularly white blood cells and platelets.
Patients who have received chemotherapy, previously or concurrently, or whose treatment volume encompasses a significant percentage of marrow are at particular risk.
Follow protocol guidelines for interruption of therapy due to hematologic toxicity.
In the absence of protocol guidelines, consider the rate of decrease in counts and clinical situation; consider holding treatment for absolute neutrophil count <1000 cells/pL or platelets < 75,000.
The role of colony-stimulating factors during radiation therapy is not yet established.
C. Management of radiation-induced nausea and vomiting
Radiation-induced nausea and vomiting can be difficult to prevent. Nausea can be seen with radiation of the head or stomach; occasionally it is also seen when other parts of the body are irradiated. The mechanisms are different, so the treatments are different.
Management of nausea and vomiting due to cranial irradiation (see below, “Side Effects of Cranial Irradiation.”)
Management of nausea and vomiting due to direct effect on the stomach
a. Etiology: not well understood
b. Treatment
i. Sipping of decarbonated cola drinks may relieve
symptoms
ii. Antiemetic medications
(1) Prochlorperazine (Compazine)
(a) Dose:
Children (>10 kg or >2 years): 0.4 mg/kg/day, by mouth (PO) or per rectum, divided t.i.d.q.i.d.
Teenagers: 5-10 mg per dose t.i.d. to q.i.d.
(b) Available:
Tablet: 5, 10, or 5 mg Syrup: 5 mg/mL Suppository: 2.5, 5, or 25 mg
(2) Metoclopromide (Reglan)
Dose: 0.1 mg/kg PO q.i.d.
Available: tablet: 5 or 10 mg Syrup: 5 mg/mL
(3) Cisapride (Propulsid)
Dose: children: 0.2-0.3 mg/kg per dose PO t.i.d. to q.i.d.
Available:
Tablet: 10 cor 20 mg Suspensions: 1 mg/mL (4) Ondansetron (*Zofran)
(a) Dose: 0.15 nmg/kg per dose; usually adminis-
tered PO p4-6h, starting 1 hour before
radiation d;.aily.
(b) Available: ts ablet: 4 or 8 mg
3. Management of nausea and vomiting due to radiation of other parts of body
a. Etiology
This is believed to be due to delayed gastric emptying.
b. Treatment
Cisapride (PropulsidH) and metoclopramide (Reglan) may have physiologic advantages by promoting gastric emptying.
LATE EFFECTS
A. Growth problems
1. Neuroendocrine effect of irradiation of hypothalamic pitu-
itary axis
2. Direct effect on irradiateed bone and soft tissue
a. Effect is age and doses dependent.
i. Irradiated bones may be smaller or shorter than
nonirradiated bonaes.
ii. Spinal irradiation imay affect height and may exacer-
bate kyphosis or sscoliosis.
b. Irradiated muscle may atrophy.
3. Management of growth problems
a. Consider growth horanone replacement.
b. Monitor for scoliosis and kyphosis.
c. Consider early plastic surgical intervention to correct
facial deformities, sutfficient to cause psychosocial dis-
tress.
d. Offer psychosocial support
B. Soft tissue fibrosis over a joint
1. Etiology
This is caused by scarr-ing after high-dose radiotherapy. The risk is increased if the field also includes a radical surgical site.
2. Prevention
If possible, plan surgical incisions to allow the radiation oncologist to avoid treating a full joint.
3. Treatment
Daily range-of-motion exercises for the rest of the patient’s life will be necessary.
C. Peripheral edema
1. Etiology
a. Lymphatic obstruction
b. Venous insufficiency
2. Prevention
Place incisions vertically, not transversely, in extremities, to allow the radiation oncologist to treat the entire scar without treating the entire circumference of the extremity.
D. Carcinogenesis
1. Risk factors for second malignant neoplasm due to radiation therapy
a. The relative risk of a second malignant neoplasm due to radiation therapy is not yet well defined, as it varies from report to report and by original disease, age at treatment, and site treated.
b. Children treated for one malignancy have an increased risk of developing a second malignant neoplasm, even in the absence of radiation therapy.
c. Genetics (heredity) plays a role.
i. Patients with basal cell nevus syndrome often develop basal cell cancers in the irradiated field 6 months to 3 years after treatment.
ii. Patients with familial retinoblastoma are at increased risk of a second malignant neoplasm, even without irradiation.
d. About two-thirds of second malignant neoplasms are found in the field of radiation therapy. Bone and soft tissue sarcomas are considered radiation induced only if they occur in the radiated treatment volume.
e. Tissue sensitivity to carcinogenesis from radiation varies.
i. Thyroid gland and breast are at risk after low doses.
ii. Lung, liver, and lymphoid tissue are at risk after moderate doses.
iii. Bone and muscle are at risk after higher doses.
f. Tissue stage of development alters risk; proliferating cells are most at risk. Girls whose breast tissue is irradiated between ages 10 and 16 (during pubertal development) have the greatest increase in risk of developing breast cancer; risk declines as the age at treatment
increases.
g. Sex is a factor. The risk of a second malignant neoplasm is higher for females than males, even excluding breast cancer.
2. Management
a. Discourage smoking in survivors, especially if the respiratory tract has been irradiated.
b. Examine tissues at risk, i.e., those in radiation treatment volume.
c. Perform scrupulous breast follow-up for women who received radiation to the breast during adolescence.
i. Monthly breast self-examination
ii. Regular clinical breast examinations; early annual mammography (exact age to start is controversial)
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REDUCING YOUR RISK OF CORONARY ARTERY DISEASE: IMPROVING YOUR ACTIVITY LEVEL BEFORE YOU START TO EXERCISE

For most people, the health advantages of regular exercise far outweigh any risks. However, if you have any chronic health conditions or several major risk factors for heart disease (such as smoking, high blood pressure high blood cholesterol, diabetes), some special precautions may apply.
To be on the safe side, check with your doctor before you begin an exercise program if you:
Have heart or lung disease, diabetes, arthritis, or kidney disease Are age 40 or older Are very overweight Have parents, brothers, or sisters who had evidence of coronary artery disease before the age of 55 Are unsure of your health status
Your doctor may recommend that you have an exercise stress test to help determine whether exercise is likely to cause an insufficient supply of blood and oxygen to the heart or to provoke heart rhythm abnormalities. Discuss with your doctor any limitations that he or she would suggest because of your existing health conditions.
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KNEE FRACTURE: IS IT DISPLACED OR NONDISPLACED?

Bone fractures tend to heal themselves in a process that I will explain later, and in most cases, your physician will simply let nature take its course. However, there are times when surgical intervention is necessary. Surgery is almost always required in the case of a displaced fracture when a bone breaks in such a way that even if it mends on its own, its normal strength and shape cannot be restored. If the fractured bone is an integral part of a joint—such as the knee—it can become the weak link in the joint, eventually destroying the anatomy and balance of the joint. For example, many older people fall and fracture their knee in an area called the tibia plateau, the location where the articular cartilage sits on the bone. If the injury displaces the tibia plateau by more than a few millimeters, it can throw off the entire alignment of the knee joint and cause severe arthritic changes. Therefore, this kind of injury requires surgical correction to restore the joint.
Diagnosis
Physical Examination. A fracture about the knee is quite painful and the patient will not move the knee very much, if at all. There will usually be immediate swelling and tenderness at the site of fracture. Within a few hours, the area will be black and blue.
An X-ray. Complete bone fractures can be diagnosed by X ray, which will show the location of the fracture and the type of break.
Computerized Axial Tomographic Scanning (CAT Scan). A CAT scan is a regular X ray that transects the bone into serial sections, either from front to back or from the side. It is sometimes used to help assess the depth of a subtle fracture.
Treatment
If the fracture is stable, that is, if the broken bones can firmly reattach, surgery is not required. The more surface area involved in the break, the more likely the fracture is stable. For example, a long spiral fracture is usually more stable than a transverse fracture that neatly splits the bone in two and has very little surface area. If the fracture is stable, the leg is casted until it mends—a so-called closed reduction procedure. Closed reduction, which requires no incision, is often performed under general anesthesia. In this procedure, the bones are put back in their normal position and held in place by a cast. When the fracture is healed, the cast is removed. An experienced knee surgeon can usually predict whether a closed reduction will be successful prior to surgery.
If, however, the fracture is unstable, that is, if the bones cannot reattach without becoming wobbly—as in the case of a transverse fracture—a surgical procedure called open reduction and internal fixation may be required. If an open reduction is necessary, it will require an appropriate incision and internal fixation of the fracture fragment with hardware, plates, screws, and, possibly, rods. The recovery time from the surgery depends on the injury and individual. The principle of rehabilitation is to allow knee joint motion as early as possible while protecting the fracture from excessive weight-bearing stress. The rehabilitation program varies depending on the type of injury.
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SURGICAL APPROACHES TO EPILEPSY: SURGERY FOR OTHER TYPES OF SEIZURES – SECTIONING OF THE CORPUS CALLOSUM

The corpus callosum is the major pathway connecting one hemisphere of the brain with the other. Some seizures that are focal or multifocal in origin will spread throughout the cortex by the pathway of the corpus callosum to become generalized tonic-clonic seizures. Others will spread by this pathway to deeper structures and lead to atonic and minor-motor drop spells. When an individual is severely handicapped by these generalized seizures, and when the seizures are unresponsive to anticonvulsant medication, sectioning of the corpus callosum may prevent spread of the seizure and abolish the generalized component. Sectioning (cutting) of the corpus callosum does not stop focal seizures, and indeed may sometimes increase them, but focal seizures are more easily tolerated than generalized ones.
After this operation, often done in two stages, there is usually a 50 to 70 percent decrease in the atonic and generalized tonic-clonic seizures. There is little experience with this procedure in young children, where its success rate and its effect on the child’s developing nervous system are less understood.
This operation seems to be gaining support as more procedures are performed and the results better defined. Unlike the hemispherectomy patients, who seem to make important gains in intellectual function after surgery and sometimes improvement in their motor function as well, after corpus callosum section, children and adults seem less likely to experience substantial intellectual or motor improvement. The life of these individuals may be dramatically improved, however, with cessation of the akinetic seizures.
Surgery can sometimes provide “the answer” to seizures that are not controllable with medication and it can sometimes “cure” seizures that are focal or one-sided. Surgery is always worth considering.
But considering surgery is a multi-step process that requires careful evaluation at each step. Surgery itself is only the final step in the decision-making process.
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DIABETES AND EXERCISE THERAPY: GAMES & DIABETES, YOGA & DIABETES GAMES & DIABETES

Diabetes patient can take part in different games but some games may be dangerous specially for fear of hypoglyceamia. Some games are not suitable like mountaineering, gliding, parachute dropping gotakhori etc. Of course these games are less popular in India. Again for safe games one must consult a doctor.
YOGA & DIABETES
The science of Yoga is very old and is a rich heritage of our Indian culture. B. K. Sahay & Co-worker from Hyderabad scientifically proved the benefits of yoga after long term followup studies. The observations of their studies are as follows:
Fasting & post prandial blood sugar came down significantly.
Patient had feeling of well-being within 10 days with lowering of dosage of drugs. regulatory hormones like Cortisol.
Fall of FFA – suggesting better utilization of insulin and decreased peripheral utilization of insulin and decreasing peripheral resistance to insulin (receptor-action).
Some special Yogic practice like PRANAYAMA, DHANURASANA, ARDHA-MATSENDRA ASANA, PACHIMOTOSANA, HALASANA & VAJRASANA etc. are very helpful in diabetes mellitus.
These are practised in empty stomach for 30 min. & followed by SHAVASANA for 10-15 min.
Patient with hypertension & diabetes were also studied.
Consult your doctor and Yoga specialist.
Conclusion : Exercise therapy, Yoga and Games play a major and vital role in control of diabetes with adjustment of diet. Selection of each diabetic patient for exercise therapy after proper screening and evaluation is mandatory with the type of exercise protocol advocated carried out under medical supervision.
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FOODS THAT PREVENT AND CONTROL CANCER: GARLIC

Garlic is an ancient remedy for cancer. Even the father of medicine, Hippocrates prescribed garlic for this disease more than two thousand years ago. It was, however, only in the twentieth century    that    scientists discovered the anti-cancer properties of garlic. The use of garlic has been found especially    valuable    in preventing stomach, lung and liver cancers. More than 30 different enemies of carcinogens have been identified in garlic and onions. Such compounds include diallyl sulphide, quercetin and ajoene. In animals, they block the most terrifying cancer-causing agents such as nitrosamines and aflatoxin, linked specifically to stomach, lung and liver cancer. In experiments, feeding garlic to animals consistently blocked cancer. Garlic also helps strengthen that part of the immune system, which directly fights tumours. It should thus form part of the diet of those who are having cancer or at risk of getting it. Various studies conducted in China, Italy and the United States during the last ten years, have conclusively proved the protective role of garlic in the diet, which can fight cancer effectively.
A five-year Designer Foods Program launched by the National Cancer Institute in U.S.A. in 1991, examined foods which were likely to prevent cancer, based on either traditional medicine or recent epidemiological studies. Among the foods selected were garlic, citrus fruit, linseed, liquorice root, and members of the parsley family. The researchers tried to ascertain the constituents in these foods which could help prevent the formation of cancer cells. According to Herbert F. Pierson, director of this program, garlic is the food with the greatest power to prevent cancer.
In 1994, research studies were conducted at the University of Minnesota to examine the relationship of diet and colon cancer in a large number of women from Iowa. These studies provided stronger scientific evidence than before, about the value of garlic in preventing colon cancer.
Michael Wargovich, at the Houston’s M.D. Anderson Cancer Center, a leading researcher on garlic, gave some mice purified diallyl sulphide from garlic, and others, plain mice food, followed by powerful carcinogens. Mice fed on the garlic substances had 75 per cent less colon tumours. More impressive, when given agents that cause oesophageal cancer in mice, not a single one getting the diallyl sulphide came down with cancer! Similarly, John Milner, head of nutrition at Penn State University, succeeded in blocking 70 per cent of breast tumours in mice by feeding them fresh garlic. Studies on humans show that those who eat more onions and garlic are less prone to various cancers.
Garlic seems to prevent cells turning cancerous by increasing the body’s natural mechanisms for removing toxic substances. The liver eliminates toxic chemicals and other substances from the body, and garlic protects the liver itself from damage. Garlic also has a deep effect on liver detoxification enzymes, which break down toxic substances and render them harmless. Garlic’s many sulphur-rich compounds appear to be responsible for this effect. Sulphur makes up about one per cent of garlic by weight, and dozens of sulphur containing compounds are present in it, especially after it has been chopped or crushed. At the cell level, these sulphur compounds bind to sensitive areas in the cell’s genetic machinery. By blocking those sites, the compounds appear to prevent cancer causing chemicals from doing their damage to the cell.
Garlic also protects against radiation-induced cancer. A certain level of radiation from the sun is normal in the atmosphere. This radiation puts the people who spend considerable time in the sun at great risk for skin cancer. Other sources of radiation in the atmosphere are pollution from energy or weapons production. Eating garlic liberally can help prevent cancer caused by radiation from all these sources.
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WHY YOU CAN’T STAY AWAKE: THE DANGERS OF SLEEP APNEA – HIGH BLOOD PRESSURE

When breathing stops, the brain signals the heart to pump more vigorously to compensate for the drop in oxygen supply. Blood pressure thus rises sharply; in severe cases, this increase can lead to cardiac arrest, which can be fatal.
One study found that patients with sleep apnea were five times as likely to have high blood pressure as those who were unaffected by nighttime breathing disturbance. Between 60 and 80 percent of patients with OSA also have hypertension. Also, about 30 percent of patients with hypertension suffer from OSA—a significantly higher incidence of OSA than that found in the general population, which is estimated to be 5 percent. Such results indicate that OSA plays a direct role in elevating blood pressure. The same study found that hypertensive patients had an average of 110 apneic episodes per night, compared with 11 experienced by nonhypertensive individuals. There are two conclusions to be drawn from such data: if you have hypertension, it should be treated in order to minimize the risk of OSA (and for many other reasons as well). Conversely, if you have OSA, it should be treated to lower the risk of developing a chronic case of high blood pressure.
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HIV: MOUTH PROBLEMS-WHITE PATCHES IN THE MOUTH: ORAL HAIRY LEUKOPLAKIA (OHL)

White patches in the mouth, sometimes painful, often painless, are most commonly symptoms of thrush, and less commonly symptoms of oral hairy leukoplakia.
White patches along the tongue and occasionally in adjacent areas in the mouth are symptoms not only of thrush, but also of oral hairy leukoplakia (OHL). Oral hairy leukoplakia is named for its location in the mouth (oral), and its appearance as white patches (leukoplakia) with microscopic hairlike protrusions (hairy) from the tongue’s surface. The patches can be a fraction of an inch in diameter or they can coat most of the tongue. Some people with oral hairy
leukoplakia have a sore mouth and occasionally have voice changes.
The symptoms of OHL resemble the symptoms of thrush, though OHL is somewhat less common. Sometimes the first clue to a diagnosis of OHL is that the person does not respond to treatment for thrush. The best way to distinguish clearly between thrush and OHL is to look at tissue taken by biopsy under the microscope. Often the patch itself is sufficiently distinctive in appearance to make a biopsy unnecessary. Most people discover the patches themselves, when they examine their mouths.
Oral hairy leukoplakia is a rather unusual condition. Its cause is unknown, but may have something to do with the Epstein-Barr virus, the virus responsible for infectious mononucleosis. Whatever the association with the Epstein-Barr virus, OHL is not considered contagious. It is found only in people with HIV infection and no one else gets it.
There is little need for treatment except for pain, for interference with nutrition, or for voice changes. The usual treatment is an antiviral drug, acyclovir, taken by mouth. Occasionally other antiviral drugs like ganciclovir are also successful. The patches disappear within two or three weeks when treated, but like thrush, they recur when the medicine is discontinued.
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THE SKIN AND AGEING: TREATING PHOTOAGEING WITH RETIN – A/RETRIEVE

Many people now in their thirties and forties are realizing that they have spent far too many hours in the sun. They are suffering the effects of photoageing and want to know what can be done about it.
Skin has the ability to repair itself from the damaging effects of sunlight. It has been shown that if you protect yourself completely from ultraviolet light, your skin will actually repair much of the sun damage. It is never too late to protect yourself from sunlight by regular use of broad spectrum sunscreens.
Retin – A/retrieve
Thanks to film stars like Cher, Retin-A has received enormous publicity as an anti-ageing preparation. There is now conclusive scientific evidence supporting the use of Retin-A to help reverse photoageing when it is used regularly over a prolonged period. It does not, however, turn back the clock on biological ageing.
It is not entirely understood how Retin-A works, but it is known that it normalizes the function of the skin’s regenerating cells. Excessive exposure to sunlight damages these cells which then produce faulty skin. Retin-A corrects this function, so more youthful skin is again produced. In order to maintain this improved function, however, Retin-A must be used on an ongoing basis.
Retin-A must be used for at least four to six months, on a daily basis, before improvements in sun-damaged skin are seen. These improvements continue as long as Retin-A is applied. Anyone who has sun-damaged skin can benefit from Retin-A, although it is not recommended for pre-pubertal children or pregnant women, and should not be used on inflamed skin. It is best to start Retin-A under medical supervision to achieve maximum results and minimize side effects. It should be introduced gradually by using it for short periods of time on alternate nights. As acclimatization occurs, it can be left on overnight without irritation. After twelve months, Retin-A need only be applied three times a week to achieve optimum results. It is preferable to start with Retin-A in cream form rather than the gel or liquid, as this is least likely to cause irritation. All areas of the face, neck and hands can be treated.
Although Retin-A is not a substitute for face-lifting, chemical peeling or dermabrasion, it is able to significantly improve skin texture and fine superficial wrinkles. Retin-A will also make the skin less sallow, lighten brown blotches and impart a healthy glow. It will, however, initially cause some mild peeling and redness, which decreases as acclimatization occurs. This initial skin irritation is a normal occurrence and does not cause any permanent damage or scarring. Using Retin-A is like getting fit, where the end result justifies the initial hardship.
Because Retin-A is being used to treat sun-damaged skin, it is essential to use a maximum protection ultraviolet A sunscreen every day to prevent further sun damage. Many sunscreens are greasy and can irritate the skin when Retin-A is being used. Ego SunSense Toddler Milk, Ego Sunsensitive, Clinique City Block, Nivea Visage, Roche Aquababy and Oil of Ulan Daily UV Protectant Moisturizer SPF 15 are recommended.
It is best not to mix Retin-A with other creams as these may dilute it, making it less effective. Because the skin is drier when Retin-A is being used, more moisturizer may be necessary during the daytime, and this should be used in conjunction with a good sunscreen. Many moisturizers irritate skin treated with Retin-A, so care must be taken when selecting them. The cosmetic industry is presently working towards developing creams which are compatible with Retin-A use. Current examples include several of the Almay moisturizers, Candermyl, Nutra-D, Neutrogena moisturizer and Simple moisturizer.
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