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Botulism: Foodborne: Cranial nerve duction appears first buy nitroglycerin 6.5mg with amex, then dilated fixed pupils (not always present) Reflex iridioplegia: Argyll Robertson pupils Optic nerve lesions: (swinging flashlight test) – MS Adie tonic pupils Unilateral dilatation: Raised intracranial pressure Chadwick D (1993) The cranial nerves and special senses purchase nitroglycerin 2.5 mg overnight delivery. In: Walton J (ed) Brain’s diseases References of the nervous system. Oxford University Press, Oxford, pp 76–126 Shintani RS, Tsuruoka S, Shiigai T (2000) Carotid cavernous fistula with brainstem conges- tion mimicking tumor on MRI. Neurology 55: 1229–1931 84 Multiple and combined oculomotor nerve palsies Fig. The optomotor nerves: 1 Oculomotor nerve, 2 Trochle- ar nerve, 3 Abducens nerve Fig. Optomotor nerves and relation to vessels and brain- stem: 1 Trigeminal ganglion, 2 Trochlear nerve, 3 Abducens nerve, 4 Oculomotor nerve, 5 Optic nerve, 6 Internal carotid artery 85 Fig. Orbital metastasis: A Atypical optomotor function; B Exophthalmos, best seen from above; C CT scan of orbital me- tastases 86 III, IV, VI Site of lesion Cause Associated findings Brainstem: Infarction Associated Leigh syndrome brainstem signs Tumor Wernicke’s disease Subarachnoid space Aneurysm Other cranial Clivus tumor nerve palsies Meningeal carcinomatosis Meningitis Trauma Cavernous sinus Aneurysm Ophthalmic division Carotid-cavernous of trigeminal nerve Fistula involved, Herpes zoster orbital swelling Infection pain Mucormycosis Mucocele Nasopharyngeal Carcinoma Pituitary apoplexy Tolosa Hunt syndrome Tumor: meningeoma Orbital Thyroid eye disease Proptosis Orbital cellulitis Pseudotumor Trauma Tumor Uncertain Cranial arteritis Pain, polymyalgia Miller Fisher syndrome Ataxia Diabetes Vincristine Toxic Differential diagnosis: orbital muscle disease including thyroid disease, MG, rare ocular myopathies Reference Garcia-Rivera CA, Zhou D, Allahyari P, et al (2001) Miller Fisher syndrome: MRI findings. Neurology 57: 1755–1769 87 Plexopathies 89 Cervical plexus and cervical spinal nerves Genetic testing NCV/EMG Laboratory Imaging Biopsy + The ventral rami of the upper cervical nerves (C1–4) form the cervical plexus. Anatomy The plexus lies close to the upper four vertebrae. The dorsal rami of C1–4 innervate the paraspinal muscles and the skin at the back of neck. Greater auricular Cutaneous nerves Greater occipital Lesser occipital Supraclavicular Transversus colli Transverse cutaneous nerve of the neck Intertransversarii cervicis (C2–C7) Muscle branches Rectus capitis anterior (C1–3) Rectus capitis lateralis (C1) Rectus capitis longus (C1–3) M. Other communicating branches exist with caudal cranial nerves and auto- nomic fibers, cervical vertebrae and joints, and nerve roots/spinal nerves (C1/C2 and C3–8). Complete cervical plexus injury: Clinical picture Sensory loss in the upper cervical dermatomes. Clinical or radiological evi- dence of diaphragmatic paralysis. High cervical radiculopathies: Less common, affected by facet joint. C2/3: site for Herpes Zoster, with post-herpetic neuralgia possible.

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Wherever phlebo-lymphological symptoms are found generic 6.5mg nitroglycerin fast delivery, the following treatments should be considered: & Mesotherapy with phlebotonics & Sequential pressure therapy & Manual lymphatic drainage & Carboxytherapy & Endermologie treatment & Use of elastic hose In the absence of phlebo-lymphological symptoms nitroglycerin 2.5mg lowest price, nonvascular causes should be investigated. The patient’s motivation is essential because—besides the information it provides—it also indicates actual psychophysical conditions. Other groups of patients, for example as S3 (patients with medium obesity) must be treated as patients with multifactorial functional diseases and they must be referred to an endocrinologist or a nutritionist. Prior consent of the patient is required for the following treatments: & Intake of a cyclic high-protein diet alternated with hyponutritional balanced diet & Oxygenclasis & 1 Systemic Endermologie (action of lymphatic drainage, lipolysis, and depuration) & 1 Eventual liposculpture associated with postsurgical Endermologie (drainage/ stimulation/invigoration) and carboxytherapy 124 & BACCI AND LEIBASCHOFF In group S4 (hyperobese patients): The patient should be referred to a specialist. Prior consent of the patient is required for the following treatments: & Prolonged intake of a high-protein diet alternated with hyponutritional balanced diet & Mesotherapy & 1 Systemic Endermologie (action of lymphatic drainage, lipolysis, and depuration) & Local treatment as required & Consideration of eventual surgery with gastric banding & Nonindication of liposculpture In group V1b [varicose disease plus advanced lipodystrophy (LPD)]: & Hygienic and dietary indications & Specific exercise & Manual lymphatic drainage plus sequential pressure therapy & 1 Endermologie cycles & Mesotherapy & Eventual superficial carboxytherapy & Oral administration of phlebotonics plus antiedematous therapy (phytotherapeutic medicines) & Foot control & Use of elastic hoses graduated in mmHg & Surgical treatment/laser/varicose pathology sclerosants In group V3 (soft lymphedema): The patient should be referred to a specialist for a clinical and instrumental phlebo-lymphological diagnosis: & Hygienic and dietary indications & Specific exercise & 1 Endermologie cycles & Carboxytherapy & Mesotherapy & Eventual sequential pressure therapy plus manual lymphatic drainage & Oral administration of phlebotonics plus antiedematous connective therapy (Cellulase 1 Gold ) & Foot control & Use of semirigid bandages alternated in cycles with elastic hoses In group V5 (lipolymphedema), clinical and instrumental (echodoppler) phlebo- lymphological diagnosis is necessary: & Hygienic and dietary indications & Exercise & 1 Endermologie cycles & Leg mesotherapy & Abdomen and thigh carboxytherapy & Antiedematous and connective therapy & Foot control & Eventually, use of elastic hoses graduated in mmHg BIMED–TCD & 125 In group F1a (initial flaccidity plus mild lipodystrophy): & 1 Endermologie treatment (action of tonification and vascularization) & Occasional mesotherapy and carboxytherapy & Ultrasonic endolifting (internal ultrasound without suction) & Foot control In group F2 (advance flaccidity): & Exercise & Use of active skin cosmetics & 1 Endermologie treatment (action of tonification and vascularization) & Nonindication for mesotherapy and carboxytherapy. Thus, a scientific cost–benefit evaluation is possible, and indications of effectiveness are available. Certainly, this classification may and should be improved. Returning to our initial example of a patient coded as G1a/S1/L2V5/A2ab, we realize at once that she belongs to the gynoid type, complains of subjective—therefore Mediterranean—symptoms, shows an increase of insulin and estrogen receptors in the lower limbs and glutei, and is probably affected by veno-lymphatic insufficiency. The patient complains of pain in both legs but comes to consul- tation because ‘‘she dislikes her appearance. Slight overweight is observed, outside of the obesity range. The patient may be controlled through mild diet and later maintenance diet. Lipedema is also detected with advanced lipodystrophic alterations plus lipolymphedema, in full accordance with local endocrine metabolic alterations and veno-lymphatic insufficiency (in the absence of vascular insufficiency, symptoms may be attributed to foot pathology with local hypoxic dysmetabolic paresthesia or to psycho-emotional dysfunction). Additionally, genuine adiposity may be detected in the abdomen and legs. After examining for oxidative stress and prescribing cleans- ing, localized liposculpture should be attempted followed by rehabilitation focused on 126 & BACCI AND LEIBASCHOFF 1 carboxytherapy and Endermologie techniques applied in combination with drainage plus stimulation and leg mesotherapy.

Gunshot: greater chance of involving the lumbar plexus generic nitroglycerin 6.5mg with visa. Most commonly generic nitroglycerin 6.5mg visa, injury is secondary to double vertical fracture dislocations of the pelvis. Resulting symptoms are in the L5 and S1 distribution with poor recovery. Pelvic fractures: Classification of pelvic fractures: stable, partially stable and unstable. Classification of sacral fractures: lateral, foraminal, transforaminal, medial foraminal. Maternal lumbosacral plexopathy (maternal paralysis): The lumbosacral trunk, superior gluteal, and obturator nerves can be com- pressed by the fetal head pushing against the pelvic rim. May happen intrapar- tum, but also occurs in the third trimester. Sensory loss at the lateral leg and dorsum of the foot. It may also be caused by prolonged labor, cephalopelvic disproportion and midpelvic forceps delivery. Femoral nerve and obturator neuropathy may also occur. Differential diagnosis: neoplastic versus radiation damage of the lumbosacral plexus: Neoplastic Radiotherapy Pain Indolent leg weakness Unilateral weakness Bilateral weakness Short latency Long latency Reflexes unilaterally absent Reflexes bilaterally absent Mass on imaging Normal MRI Palpable mass Myokymia in EMG Leg edema Paraspinal fibrillations Hydronephrosis High dose therapy Episodic weakness of lumbosacral plexus (Table 8) Diagnosis Laboratory: exclude diabetes Imaging: radiograph, CT, MRI CT or MR angiography for suspected vascular lesions CSF: when cauda equina lesion or inflammatory lesion is suspected Electrophysiology: motor and sensory studies: NCV, late response, needle EMG, evoked potentials Bulbocavernosus reflex Table 8. Episodic weakness of the lumbosacral plexus Episodic weakness of the lumbosacral plexus Cauda equina lesion Exacerbated walking Lumbar vertebrostenosis, downhill improves when bending Unaffected by bicycling forward, less symptoms Pain & Sensory loss: distal when cycling Ischemic plexopathy Pain: distal No progressive sensory-motor loss during exercise Distal pulses: reduced or absent Peripheral arterial Local pain radiating into hip occlusive disease and thigh (exercise dependent) (From Wohlgemuth, 2002). CMAP: axon loss SNAP: extraforaminal from canal root therefore are absent in plexopathy Paraspinal muscles are normal with plexopathies Lumbar plexus: Sensory NCV EMG Saphenous nerve Femoral quadriceps L2-L4 Lat. In: Campell WW (ed) Essentials of electrodiagnostic References medicine. Williams & Wilkins, Baltimore, pp 207–224 Dyck PJB, Windebank AJ (2002) Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: new insights into pathophysiology and treatment. Muscle Nerve 25: 477–491 Feasby TE, Burton SR, Hahn AF (1992) Obstetrical lumbosacral plexus injury. Muscle Nerve 15: 937–940 Jaeckle KA (1991) Nerve plexus metastases.

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Medical history should include the patient’s structural diagram purchase nitroglycerin 6.5mg line, details of the cel- lulite areas discount nitroglycerin 6.5mg without prescription, a possible therapeutic strategy, and photographs from different angles taken 96 & LEIBASCHOFF during the first visit, halfway through therapy, and at the end of treatment. Maintenance therapy may vary, being just dietary–hygienic and physical (diet and cycles of monthly ses- 1 sions of Endermologie ), or medical–physical (monthly sessions of carboxytherapy or mesotherapy plus subdermal therapy) (2). As for the measurement of bitrochanteric, knee, and calf circumference, we believe they are not important. We know, in fact, that frequently circumference reduction is com- bined with tissue alterations and loose tissue. Circumference reduction due to a decrease in excessive adipose tissue––subcutaneous or steatomeric––is different from circumference reduction in the cellulite pathology. This difference should be thoroughly explained to patients to discredit false popular beliefs. Non-invasive assessment of the effectiveness of cellasene in patients with oedematous fibrosclerotic panniculopathy (cellulitis): a double-blind prospective study. Int J Cosmet Surg Aesthet Dermatol 2001; 3(4):265–273. Atti 1 Congr Multid Chir Plast e Invecch, Roma, Italy, 1989. Valutazione clinica controllata in doppio cieco di prodotti fitocomposti nel trattamento della cosiddetta cellulite. Efficacy of a multifunctional plant complex in the treatment of a localised fat-lobular hypertrophy. Echodoppler coleur et exploration veineuse superficielle. Physiological effects of endermologie: a preliminary report. Valutazione sull’attivita` microcircolatoria della tecnica endermologie LPG in paziente con PEFS (1997).

2017, Valdosta State University, Vak's review: "Nitroglycerin 6.5 mg, 2.5 mg. Best Nitroglycerin online.".

Botulism: Foodborne: Cranial nerve duction appears first buy nitroglycerin 6.5mg with amex, then dilated fixed pupils (not always present) Reflex iridioplegia: Argyll Robertson pupils Optic nerve lesions: (swinging flashlight test) – MS Adie tonic pupils Unilateral dilatation: Raised intracranial pressure Chadwick D (1993) The cranial nerves and special senses purchase nitroglycerin 2.5 mg overnight delivery. In: Walton J (ed) Brain’s diseases References of the nervous system. Oxford University Press, Oxford, pp 76–126 Shintani RS, Tsuruoka S, Shiigai T (2000) Carotid cavernous fistula with brainstem conges- tion mimicking tumor on MRI. Neurology 55: 1229–1931 84 Multiple and combined oculomotor nerve palsies Fig. The optomotor nerves: 1 Oculomotor nerve, 2 Trochle- ar nerve, 3 Abducens nerve Fig. Optomotor nerves and relation to vessels and brain- stem: 1 Trigeminal ganglion, 2 Trochlear nerve, 3 Abducens nerve, 4 Oculomotor nerve, 5 Optic nerve, 6 Internal carotid artery 85 Fig. Orbital metastasis: A Atypical optomotor function; B Exophthalmos, best seen from above; C CT scan of orbital me- tastases 86 III, IV, VI Site of lesion Cause Associated findings Brainstem: Infarction Associated Leigh syndrome brainstem signs Tumor Wernicke’s disease Subarachnoid space Aneurysm Other cranial Clivus tumor nerve palsies Meningeal carcinomatosis Meningitis Trauma Cavernous sinus Aneurysm Ophthalmic division Carotid-cavernous of trigeminal nerve Fistula involved, Herpes zoster orbital swelling Infection pain Mucormycosis Mucocele Nasopharyngeal Carcinoma Pituitary apoplexy Tolosa Hunt syndrome Tumor: meningeoma Orbital Thyroid eye disease Proptosis Orbital cellulitis Pseudotumor Trauma Tumor Uncertain Cranial arteritis Pain, polymyalgia Miller Fisher syndrome Ataxia Diabetes Vincristine Toxic Differential diagnosis: orbital muscle disease including thyroid disease, MG, rare ocular myopathies Reference Garcia-Rivera CA, Zhou D, Allahyari P, et al (2001) Miller Fisher syndrome: MRI findings. Neurology 57: 1755–1769 87 Plexopathies 89 Cervical plexus and cervical spinal nerves Genetic testing NCV/EMG Laboratory Imaging Biopsy + The ventral rami of the upper cervical nerves (C1–4) form the cervical plexus. Anatomy The plexus lies close to the upper four vertebrae. The dorsal rami of C1–4 innervate the paraspinal muscles and the skin at the back of neck. Greater auricular Cutaneous nerves Greater occipital Lesser occipital Supraclavicular Transversus colli Transverse cutaneous nerve of the neck Intertransversarii cervicis (C2–C7) Muscle branches Rectus capitis anterior (C1–3) Rectus capitis lateralis (C1) Rectus capitis longus (C1–3) M. Other communicating branches exist with caudal cranial nerves and auto- nomic fibers, cervical vertebrae and joints, and nerve roots/spinal nerves (C1/C2 and C3–8). Complete cervical plexus injury: Clinical picture Sensory loss in the upper cervical dermatomes. Clinical or radiological evi- dence of diaphragmatic paralysis. High cervical radiculopathies: Less common, affected by facet joint. C2/3: site for Herpes Zoster, with post-herpetic neuralgia possible.

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Wherever phlebo-lymphological symptoms are found generic 6.5mg nitroglycerin fast delivery, the following treatments should be considered: & Mesotherapy with phlebotonics & Sequential pressure therapy & Manual lymphatic drainage & Carboxytherapy & Endermologie treatment & Use of elastic hose In the absence of phlebo-lymphological symptoms nitroglycerin 2.5mg lowest price, nonvascular causes should be investigated. The patient’s motivation is essential because—besides the information it provides—it also indicates actual psychophysical conditions. Other groups of patients, for example as S3 (patients with medium obesity) must be treated as patients with multifactorial functional diseases and they must be referred to an endocrinologist or a nutritionist. Prior consent of the patient is required for the following treatments: & Intake of a cyclic high-protein diet alternated with hyponutritional balanced diet & Oxygenclasis & 1 Systemic Endermologie (action of lymphatic drainage, lipolysis, and depuration) & 1 Eventual liposculpture associated with postsurgical Endermologie (drainage/ stimulation/invigoration) and carboxytherapy 124 & BACCI AND LEIBASCHOFF In group S4 (hyperobese patients): The patient should be referred to a specialist. Prior consent of the patient is required for the following treatments: & Prolonged intake of a high-protein diet alternated with hyponutritional balanced diet & Mesotherapy & 1 Systemic Endermologie (action of lymphatic drainage, lipolysis, and depuration) & Local treatment as required & Consideration of eventual surgery with gastric banding & Nonindication of liposculpture In group V1b [varicose disease plus advanced lipodystrophy (LPD)]: & Hygienic and dietary indications & Specific exercise & Manual lymphatic drainage plus sequential pressure therapy & 1 Endermologie cycles & Mesotherapy & Eventual superficial carboxytherapy & Oral administration of phlebotonics plus antiedematous therapy (phytotherapeutic medicines) & Foot control & Use of elastic hoses graduated in mmHg & Surgical treatment/laser/varicose pathology sclerosants In group V3 (soft lymphedema): The patient should be referred to a specialist for a clinical and instrumental phlebo-lymphological diagnosis: & Hygienic and dietary indications & Specific exercise & 1 Endermologie cycles & Carboxytherapy & Mesotherapy & Eventual sequential pressure therapy plus manual lymphatic drainage & Oral administration of phlebotonics plus antiedematous connective therapy (Cellulase 1 Gold ) & Foot control & Use of semirigid bandages alternated in cycles with elastic hoses In group V5 (lipolymphedema), clinical and instrumental (echodoppler) phlebo- lymphological diagnosis is necessary: & Hygienic and dietary indications & Exercise & 1 Endermologie cycles & Leg mesotherapy & Abdomen and thigh carboxytherapy & Antiedematous and connective therapy & Foot control & Eventually, use of elastic hoses graduated in mmHg BIMED–TCD & 125 In group F1a (initial flaccidity plus mild lipodystrophy): & 1 Endermologie treatment (action of tonification and vascularization) & Occasional mesotherapy and carboxytherapy & Ultrasonic endolifting (internal ultrasound without suction) & Foot control In group F2 (advance flaccidity): & Exercise & Use of active skin cosmetics & 1 Endermologie treatment (action of tonification and vascularization) & Nonindication for mesotherapy and carboxytherapy. Thus, a scientific cost–benefit evaluation is possible, and indications of effectiveness are available. Certainly, this classification may and should be improved. Returning to our initial example of a patient coded as G1a/S1/L2V5/A2ab, we realize at once that she belongs to the gynoid type, complains of subjective—therefore Mediterranean—symptoms, shows an increase of insulin and estrogen receptors in the lower limbs and glutei, and is probably affected by veno-lymphatic insufficiency. The patient complains of pain in both legs but comes to consul- tation because ‘‘she dislikes her appearance. Slight overweight is observed, outside of the obesity range. The patient may be controlled through mild diet and later maintenance diet. Lipedema is also detected with advanced lipodystrophic alterations plus lipolymphedema, in full accordance with local endocrine metabolic alterations and veno-lymphatic insufficiency (in the absence of vascular insufficiency, symptoms may be attributed to foot pathology with local hypoxic dysmetabolic paresthesia or to psycho-emotional dysfunction). Additionally, genuine adiposity may be detected in the abdomen and legs. After examining for oxidative stress and prescribing cleans- ing, localized liposculpture should be attempted followed by rehabilitation focused on 126 & BACCI AND LEIBASCHOFF 1 carboxytherapy and Endermologie techniques applied in combination with drainage plus stimulation and leg mesotherapy.

Gunshot: greater chance of involving the lumbar plexus generic nitroglycerin 6.5mg with visa. Most commonly generic nitroglycerin 6.5mg visa, injury is secondary to double vertical fracture dislocations of the pelvis. Resulting symptoms are in the L5 and S1 distribution with poor recovery. Pelvic fractures: Classification of pelvic fractures: stable, partially stable and unstable. Classification of sacral fractures: lateral, foraminal, transforaminal, medial foraminal. Maternal lumbosacral plexopathy (maternal paralysis): The lumbosacral trunk, superior gluteal, and obturator nerves can be com- pressed by the fetal head pushing against the pelvic rim. May happen intrapar- tum, but also occurs in the third trimester. Sensory loss at the lateral leg and dorsum of the foot. It may also be caused by prolonged labor, cephalopelvic disproportion and midpelvic forceps delivery. Femoral nerve and obturator neuropathy may also occur. Differential diagnosis: neoplastic versus radiation damage of the lumbosacral plexus: Neoplastic Radiotherapy Pain Indolent leg weakness Unilateral weakness Bilateral weakness Short latency Long latency Reflexes unilaterally absent Reflexes bilaterally absent Mass on imaging Normal MRI Palpable mass Myokymia in EMG Leg edema Paraspinal fibrillations Hydronephrosis High dose therapy Episodic weakness of lumbosacral plexus (Table 8) Diagnosis Laboratory: exclude diabetes Imaging: radiograph, CT, MRI CT or MR angiography for suspected vascular lesions CSF: when cauda equina lesion or inflammatory lesion is suspected Electrophysiology: motor and sensory studies: NCV, late response, needle EMG, evoked potentials Bulbocavernosus reflex Table 8. Episodic weakness of the lumbosacral plexus Episodic weakness of the lumbosacral plexus Cauda equina lesion Exacerbated walking Lumbar vertebrostenosis, downhill improves when bending Unaffected by bicycling forward, less symptoms Pain & Sensory loss: distal when cycling Ischemic plexopathy Pain: distal No progressive sensory-motor loss during exercise Distal pulses: reduced or absent Peripheral arterial Local pain radiating into hip occlusive disease and thigh (exercise dependent) (From Wohlgemuth, 2002). CMAP: axon loss SNAP: extraforaminal from canal root therefore are absent in plexopathy Paraspinal muscles are normal with plexopathies Lumbar plexus: Sensory NCV EMG Saphenous nerve Femoral quadriceps L2-L4 Lat. In: Campell WW (ed) Essentials of electrodiagnostic References medicine. Williams & Wilkins, Baltimore, pp 207–224 Dyck PJB, Windebank AJ (2002) Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: new insights into pathophysiology and treatment. Muscle Nerve 25: 477–491 Feasby TE, Burton SR, Hahn AF (1992) Obstetrical lumbosacral plexus injury. Muscle Nerve 15: 937–940 Jaeckle KA (1991) Nerve plexus metastases.

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Medical history should include the patient’s structural diagram purchase nitroglycerin 6.5mg line, details of the cel- lulite areas discount nitroglycerin 6.5mg without prescription, a possible therapeutic strategy, and photographs from different angles taken 96 & LEIBASCHOFF during the first visit, halfway through therapy, and at the end of treatment. Maintenance therapy may vary, being just dietary–hygienic and physical (diet and cycles of monthly ses- 1 sions of Endermologie ), or medical–physical (monthly sessions of carboxytherapy or mesotherapy plus subdermal therapy) (2). As for the measurement of bitrochanteric, knee, and calf circumference, we believe they are not important. We know, in fact, that frequently circumference reduction is com- bined with tissue alterations and loose tissue. Circumference reduction due to a decrease in excessive adipose tissue––subcutaneous or steatomeric––is different from circumference reduction in the cellulite pathology. This difference should be thoroughly explained to patients to discredit false popular beliefs. Non-invasive assessment of the effectiveness of cellasene in patients with oedematous fibrosclerotic panniculopathy (cellulitis): a double-blind prospective study. Int J Cosmet Surg Aesthet Dermatol 2001; 3(4):265–273. Atti 1 Congr Multid Chir Plast e Invecch, Roma, Italy, 1989. Valutazione clinica controllata in doppio cieco di prodotti fitocomposti nel trattamento della cosiddetta cellulite. Efficacy of a multifunctional plant complex in the treatment of a localised fat-lobular hypertrophy. Echodoppler coleur et exploration veineuse superficielle. Physiological effects of endermologie: a preliminary report. Valutazione sull’attivita` microcircolatoria della tecnica endermologie LPG in paziente con PEFS (1997).