Types of Heart Valves

The heart valves that lie between the atria and ventricles are known as the atrioventricular (AV) valves. These valves are also known as cuspid valves because it has flaps or cusps that close together to form a seal when the ventricles are pumping. This prevents blood in the ventricle from flowing in the wrong direction, which is into the atria. The valves at the junction of the ventricles and great arteries are known as the semilunar valves due to the shape of the leaflets. It prevents blood that leaves the ventricle and enters the respective artery from flowing backwards when the ventricle relaxes.

What are the names of the four heart valves?

The heart valves are as follows :

• Atrioventricular Valves
  • Tricuspid valve lies between the right atrium and right ventricle. It has three flaps.
  • Bicuspid valve or mitral valve lies between the left atrium and left ventricle. It has two flaps.
• Semilunar Valves
  • Pulmonary valve or pulmonic valve lies between the right ventricle and pulmonary artery.
  • Aortic valve lies between the left ventricle and aorta.

How do the heart valves work?

All the heart valves work in the same way, which is to close when the blood is about to flow backwards. However, the process is a little more complex than this.

Atrioventricular Valves

The atrioventricular (AV) valves are made up of flaps that are attached via tendons known as chordae tendinae to small papillary muscles on the heart wall. It allows blood to pass from the atria into the ventricles. When the ventricle contracts the blood pushes the flaps of the AV valve together. However, the force of ventricular contraction may cause the valve to bend backwards but the papillary muscles contract thereby pulling on the chorda tendinae. This holds the flaps of the AV valves firm against the force of the blood pushing on it.

Semilunar Valves

The semilunar valves are like small cups that are flat against the vessel wall when blood is flowing in the right direction. This is during ventricular contraction when blood is expelled out of the heart and through the respective artery (pulmonary artery from the right ventricle, aorta from the left ventricle). However, at the end of ventricular contraction, the blood in the arteries begin to flow backward into the ventricle. This immediately fills the small cups of the respective semilunar valve which enlarges and closes. In this way, blood cannot enter the ventricle from the artery.

Types of Bacteria

Bacteria are known as prokaryotes because it has a cell membrane but its nucleus lacks a membrane. There are a number of terms used to categorize bacteria and this can sometimes be confusing. Firstly bacteria are single-celled organisms that may either need oxygen to survive (aerobic) or can sustain itself in the absence of oxygen (anerobic). Secondly,  most bacteria have a cell wall which may vary in thickness. Those bacteria with a thick cell wall are known as gram-positive bacteria because its wall can stain with certain dyes used to highlight the microbe for microscopic examination in a laboratory. Bacteria with thin walls are gram-negative. Lastly, bacteria come in various different shapes and this too can be used for classification. With regards to shape, rod-shaped bacteria are known as bacilli while spherical bacteria are known as cocci.

Below is a picture of E.coli bacilli which are found in large numbers in the gut. Picture from Wikimedia Commons.

Bacterial Infections

Some bacteria are pathogenic meaning that it can cause disease. This is because of certain genes that allow the bacteria to have this effect. These bacteria will then cause tissue damage by releasing toxins, adhering to cells or invading cells which are then destroyed. Some bacterial species may be able to do more than one of these actions thereby making it more virulent (harmful).

Pathogenic vs Non-Pathogenic Bacteria

The reason why some bacteria are pathogenic and others not is due to the genetic structure. Pathogenic bacteria have virulence genes which allow it to cause an infection. However, non-pathogenic bacteria which may lack these genes can be transformed when infected by viruses. These plasmids and bacteriophages are viruses that genetically ‘reprogram’ the bacteria and make it virulent. Apart from this virulence, bacteria can consume any living or dead matter and the body’s immune system keeps it at bay. If the immune system is severely compromised, even non-pathogenic bacteria that live on or in the human body will being to consume tissue that is the most prone.

Bacterial infections tend to progress rapidly once it arises and if the immune system cannot contain it, or medical treatment by the means of antibiotics are not commenced soon enough, the infection can spread. It directly infiltrate surrounding tissue, cause the formation of abnormal passages between two hollow organs known as a fistula and infect the new site, or spread to distant sites through the blood (bacteremia), lymph or other fluid and semi-solid media in the body.

Signs and Symptoms of a Bacterial Infections

The clinical features are largely associated with localized inflammation and systemic response to the invading pathogen. These signs and symptoms may include :

• Pain at the site of the infection
• Redness of the tissue
• Swelling of the affected area
• Warmth at the site
• Pus, oozing or accumulated in an abscess
• Fever

Normal Stool and Diarrhea Stool

Stool is usually firm but soft, well formed and brown in color. Although most of the stool is composed of water, it is a soft solid material. Normal bowel movements can vary from twice a day to three times in a week and depends on the individual’s normal patterns.

Diarrhea is a result of deranged motility, or more specifically hypermotility, where the contents in the gut move faster than normal. Water is either ‘dumped’ into the gut (secretory diarrhea) or is not absorbed to the extent that it normally is (osmotic diarrhea). Gas in the lower parts of the gut which is passed out through the anus (flatus) is primarily a byproduct of bacterial action in the bowels, chemical reactions caused by the digestive enzymes and to a lesser extent from air swallowed through the mouth.

With explosive diarrhea, all these mechanisms of diarrhea are exaggerated. Watery stool, or sometimes almost entirely water on its own, is propelled out with such a violent force that it sounds ‘explosive’, sputtering that may soil the person’s bottom and mess the toilet bowel and is usually accompanied by excessive flatus.

Causes of Explosive Diarrhea

Explosive diarrhea is more likely to be seen in acute diarrhea or acute aggravations of chronic diarrhea. Typically the diarrhea lasts for only a few days and resolves spontaneously or with minor medical treatment.

The most common of the acute causes are infectious diarrhea. This is primarily viral in origin and is accompanied by nausea, vomiting, abdominal cramping and sometimes fever, similar to the influenza. Hence, it is often referred to as the stomach flu. Bacterial and parasitic infections may also cause explosive diarrhea. Parasitic infections tend to be longer lasting.

Food poisoning is caused by the ingestion of food that is tainted with bacterial toxins. This irritates the lining of the bowel. Diarrhea is often preceded by severe upper abdominal pain, intense nausea and violent vomiting. If the causative tainted food is expelled entirely before it enters the intestines, it is possible that diarrhea will not ensue.

Certain drugs and substances can also cause explosive diarrhea, particularly if these compounds act specifically on the bowels. This includes laxatives and large doses of magnesium-containing antacids. Antibiotic-associated diarrhea arises with an overgrowth of Clostridium difficile bacteria. It is a common causes of explosive diarrhea following the use of antibiotics. Poisoning with toxic compounds and heavy metals may also cause violent diarrhea.

Malabsorption that leads to explosive diarrhea is largely chronic in nature but may present occasionally with acute exacerbations. This is primarily seen in foods intolerance like with lactose intolerance, gluten intolerance, sorbitol malabsorption and fructose malabsorption. The causative food substance is not well tolerated and cannot be digested or absorbed fully thereby leading to explosive diarrhea. Other causes of malabsorption are seen with structural defects of the bowel, deficiency or lack of certain digestive enzymes and the use of certain drugs.

Although less common, any other cause of diarrhea may also present with acute episodes of explosive diarrhea and this includes conditions like inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and excessive ingestion of certain foods that serve as an irritant to the bowel.

Diagnosis of Asthma

The purpose of diagnostic investigation is to first rule out other conditions and secondly to assess the severity of the asthma. A thorough case history allows the doctor to identify the characteristic signs and symptoms of asthma, assess the severity and monitor the success of the treatment in the future. It is accompanied by a thorough examination of the respiratory system and identification of other clinical features that may or may not be related to asthma.

There are four broad categories for the classification of asthma :

• Mild intermittent asthma where the symptoms such as wheezing, breathlessness and/or coughing are mild and present at most 2 days in a week and not more than 2 nights in a month.
• Mild persistent asthma where the symptoms occur more than twice in a week but is limited to at most one episode in a day.
• Moderate persistent asthma where the symptoms occur only once a day and more than one night in a week.
• Severe persistent asthma where the symptoms continue throughout the day on most days of the week and often arises at night as well.

Specialized investigation will more accurately measure the functioning of the respiratory system and this is known as pulmonary function tests, or simply lung function tests. Spirometry and peak flow are the two most widely used methods to assess the respiratory function. With spirometry, the volume of air can be measured which correlates with the degree of narrowing of the airway. A peak flow meter measures the force of expiration. Both tests are difficult to perform on younger children as it requires patient cooperation. Other tests like a metacholine challenge and nitric oxide test will also confirm the diagnosis of asthma. Allergen testing may be useful for patients with allergic asthma as it helps to identify trigger factors.

Treatment of Asthma

Asthma treatment depends on a number of factors like the severity of the condition or whether it is allergic asthma or non-allergic asthma. The medication can be divided into acute treatment and chronic/long term treatment. The aim of asthma management is to prevent acute attacks or at least minimize the frequency of these attacks while easing, or if possible even resolving, the symptoms. However, the symptoms will often return should the medication be discontinued and therefore it is imperative that asthmatic patients adhere to the treatment protocol laid out by the doctor.

Both acute and chronic medication may be inhaled or ingested (orally) although some acute medication can be administered intravenously. The range of medication may have one or more of the following effects :

• Reduce airway inflammation – corticosteroids, beta agonists (adrenergic)
• Open the airways (bronchodilation) – beta agonists, theophylline, anticholinergic

For allergic asthma, a combination of drugs along with antihistamines and decongestants may be used to reduce the allergic response, reduce airways inflammation and open the airways.

Read more on asthma information.

Simple Explanation of Asthma

Asthma is the chronic inflammation of the bronchi and bronchioles due to an increased hypersensitivity of the walls of the airways. When the walls of the bronchi and bronchioles are inflamed, it swells, secretes more mucus and the muscles in the wall may constrict. All of these effects serves to narrow the lumen of the airway and therefore restrict airflow.

In asthma, the reason for this narrowing is that the walls of the airway are extremely sensitive (hypersensitivity) and react to various stimuli (hyper-responsive) that may not affect other individuals. This is referred to as allergic asthma. It is associated with atopy, a constitutional allergic state, which also gives rise to other allergic conditions like atopic dermatitis and allergic rhinitis. These three conditions – atopic dermatitis, asthma and allergic rhinitis – are referred to as the allergic triad.

However, sometimes asthma is not related to allergies and may be termed non-allergic asthma. This is more frequently seen in the workplace (occupational asthma). There is usually underlying airway disease that causes narrowing and obstruction. Asthma may also be associated with certain drugs, like aspirin, and physical activity despite the absence of allergies. It is more likely for these types of asthma to be seen in a person with a history of childhood asthma.

Causes of Asthma

As discussed above, asthma is due to a hyper-reactive airway that is triggered by the inhalation of allergens. This commonly includes :

• House dust mite (HDM)
• Pollen
• Animal dander (particularly from pets)
• Cockroaches
• Fungi and molds

Organic and non-organic dusts, fumes from gases, smoke, certain drugs and exercise may all exacerbate existing asthma and long term exposure may even lead to the development of asthma.

Signs and Symptoms

Asthma is sometimes commonly referred to as wheezing. However, the term wheeze describes the abnormal breathing sound characteristic of asthma. It typically sounds as a whistling or rattling noise that is associated with the labored breathing. Other signs and symptoms includes shortness of breath, tightness of the chest and coughing. Patients often report the symptoms worsening with cold weather, exercise, exposure to cigarette smoke, dust and other allergens, as well as with a common cold or flu.

Asthmatics may be asymptomatic (have no symptoms) between attacks and acute episodes can very severe and even require hospitalization. It is possible, however, for an asthmatic patient to experience ongoing symptoms for weeks and months with no easing of symptoms for even short periods. Some forms of asthma like cough-variant asthma may not present with the typical signs and symptoms apart from coughing. At other times, some patients may only experience symptoms at night when asleep – nocturnal asthma. It is therefore not uncommon for asthma to be initially mistaken for chest infections and other respiratory illnesses.

Read more on asthma diagnosis and treatment.

How does diabetes affect the blood sugar levels?

In order to understand the pathogenesis behind diabetes mellitus, it is important to know how the pancreas regulates the blood sugar levels by the action of insulin. The pancreas is a gland located in the upper abdomen and secretes several hormones, including insulin. Absorption of glucose from the digestive tract and production in the liver elevates the blood glucose levels.

The pancreas responds by secreting insulin which promotes the uptake of glucose by the cells of the body as well as slowing down absorption from the gut and release of glucose by the liver. This lowers the blood glucose levels. In diabetes mellitus there is either deficiency of insulin or the body becomes unresponsive to insulin. This allows the blood glucose levels to remain elevated which causes damage to cells throughout the body.

Types of Diabetes Mellitus

There are broadly three types of diabetes mellitus known as type 1, type 2 and gestational diabetes.

Type 1 Diabetes

The onset of type 1 diabetes is early in life, more commonly in adolescence, is a result of destruction of the beta cells of the pancreas produces insulin. It was previously known as juvenile diabetes. Gradually the insulin levels drop until the pancreas is almost completely unable to produce any insulin. Therefore patients require insulin injections and it is referred to as insulin-dependent diabetes mellitus (IDDM).

Types 2 Diabetes

This type of diabetes typically occurs later in life, after the age of 40 years, although it frequently seen these days in younger individuals. This may be associated with the prevalence of obesity in younger age groups. In type 2 diabetes, the body’s cells do not respond to insulin as it normally would. Medication promotes the uptake of glucose by the cells but may reach a stage where insulin has to be administered. It is also known as non-insulin dependent diabetes mellitus (NIDDM).

Gestational Diabetes

As the name suggests, gestational diabetes develops in expectant mothers during pregnancy. It should not be confused with type 1 or type 2 diabetes which may have been pre-existing prior to pregnancy. The exact cause of gestational diabetes is not conclusively known. It is believed that hormones associated with pregnancy disrupts the cell’s responsiveness to insulin. Glucose tolerance may restore to normal after childbirth, however, the mother is at a greater risk of developing type 2 diabetes later in life.

Prediabetes

Prediabetes or impaired glucose tolerance (IGT) is similar to type 2 diabetes and often precedes type 2 diabetes but is reversible. The degree of insulin unresponsiveness in prediabetes is not to the same extent as in diabetes mellitus and patients will not record elevated blood glucose levels as high as in diabetes mellitus. Exercise, dietary change and weight loss can reverse prediabetes. However, once it reaches the stage of diabetes mellitus, it is irreversible.

Definition : Gastritis

Gastritis is the medical term for inflammation of the stomach as a whole but tends to more commonly affect the inner linings of the stomach wall. It is one of the most common ailments of the digestive system and every person experiences the odd episode of gastritis a few times in life. Gastritis may be acute or chronic. The chronic form of gastritis can persist for years or decades and cause a great amount of distress for any sufferer. It tends to occur as recurrent episodes of acute gastritis but in some cases, the inflammation is persistent and never eases despite short periods of less intense inflammation.

The gastric mucosa produces a layer of mucus which lines the inner wall of the stomach. This mucus layer protects the stomach lining from the action of the highly corrosive gastric acid and digestive enzymes contained within the stomach. Most of the causes of gastritis interfere with this mucus layer thereby exposing the inner lining of the stomach to the action of the gastric acid and digestive enzymes.

Causes of Gastritis

The two most common causes of gastritis are an H.pylori infection and the use of NSAIDs. H.pylori (Helicobacter pylori) is a type of bacteria that can withstand the stomach acid, manoeuvre itself towards the stomach lining where it attaches and compromises the mucus layer. NSAIDs (non-steroidal anti-inflam,atory drugs) also disrupt this mucus barrier.

Other causative factors are often not given as much attention but are still significant causes of gastritis. This includes trauma to the stomach, radiation, autoimmune disorders, infections other than H.pylori, pernicious anemia, allergies, food poisoning, corrosives, extreme stress, medication other than NSAIDs, substance abuse and extreme stress.

Signs and Symptoms of Gastritis

Gastritis is often asymptomatic and apart from acute episodes, many people with gastritis are not aware of it. While gastritis usually presents with severe upper left abdominal burning pain, it is also possible for the other signs and symptoms of gastritis to be present without any pain. Some of the other features of gastritis includes :

• Excessive belching
• Nausea and sometime vomiting
• Bloating
• Indigestion – a feeling of an upset stomach
• Loss of appetite
• Gastric bleeding that may present as the vomiting of coffee grounds or bright blood, or the passing of black, tarry stools.

If left untreated, gastritis will progress to a peptic ulcer, severe gastric bleeding and even stomach cancer.

Gastritis Diagnosis and Treatment

While the repeated episodes of the gastritis symptoms above may be sufficient for a diagnosis, various diagnostic investigations should be considered for chronic cases. This includes an upper gastrointestinal (GI) endoscopy, blood and stool tests.

Treatment depends on the cause and should involve both lifestyle measures and sensible eating to avoid trigger foods. Acid suppression is necessary in all cases and may require a combination of antacids, H2-blockers and/or proton pump inhibitors (PPIs). Antibiotics are necessary for H.pylori infection and eradication treatment may have to be repeated in order to totally resolve the infection.

Blood Clots in the Arteries

The arteries are blood vessels that carry oxygenated and nutrient-rich blood to various parts of the body.  The only exception to this is the pulmonary artery that carries deoxygenated (oxygen deficient) blood from the right ventricle of the heart to the lungs for oxygenation. Veins carry deoxygenated blood back to the heart except for the pulmonary veins that carry oxygenated blood back from the lungs to the left atrium of the heart so that it can be pumped out by the left ventricle and distributed to the rest of the body.

Blood in the arteries are traveling under high pressure. The arteries have thick elastic and muscular walls to cope with this high pressure, recoil and keep blood propelled and constrict or dilate as necessary. When a blood clot partially obstructs blood flow in an artery, the target organ or part of the body is deprived of an adequate supply of oxygen. If the clot is small then the oxygen supply is not compromised significantly and a person will remain asymptomatic. At most a person may experience symptoms of hypoxia (low oxygen supply) when there is an increase in demand for oxygen like at times of additional activity or stress. When the blood vessel is blocked to a large degree or in the worst case scenario even completely, then the tissue of the target area may undergo severe injury known as ischemia and even die (infarct).

Causes of Blood Clots in the Arteries

The most common cause of blood clots in the arteries is associated with damage to the inner wall of the artery. This may occur with hypertension (high blood pressure) and hyperlipidemia (high blood fats) which often leads to atherosclerosis. This is a condition where fatty plaques form in the inner wall of the artery. The partial occlusion of the artery by these plaques causes a turbulence in the blood flow through the artery. A clot is more likely to form in these cases. If a plaque ruptures, a blood clot will form quite rapidly at the site. Other causative factors of blood clot formation include :

• Diabetes melltius
• Vasculitis
• Polycythemia
• Hypercoagulability
• Infection of the artery

There are a host of other causes that may promote blood clot formation either directly or indirectly. It is more frequently associated with the following risk factors :

• Sedentary lifestyle
• Obesity
• Cigarette smoking

When a blood clot forms at a site in the artery it is known as a thrombus. However, sometimes the clot may dislodge and then travel through the artery only to lodge elsewhere. A “runaway” clot is known as an embolus.

Blood Clot in the Leg Artery

A blood clot in the leg arteries gradually reduces blood supply to the lower leg and particularly the feet. This is known as peripheral arterial disease (PAD). It often develops gradually and associated with atherosclerosis. Blood flow to the leg may not be severely hampered when a person is standing as the effect of gravity allows blood to ‘squeeze’ through past the clot. Symptoms are often reported when there is increased activity of the oxygen-hungry leg muscles like when walking or running. The pain that arises with these activities is due to ischemia and is know as claudication. The legs may also pain at night when sleeping and lying flat and patients often experience some relief by hanging the leg over the bed so that the action of gravity can help with blood flow.

Blood Clot in the Lung Artery

A blood clot that obstructs the pulmonary artery which carries deoxygenated blood to the heart is known as a pulmonary embolism. It is a very serious condition and can be life threatening. The blood flow to the lungs is hampered, blood cannot be oxygenated and backs up in the right side of the heart. Less blood returning to the right side means that there is a lower systemic oxygen supply. These blood clots rarely form at the site but often break away from a clot elsewhere in the body particularly from the leg veins as is the case with deep venous thrombosis (DVT).

Blood Clot in the Brain Artery

A blood clot in the arteries to the brain may lead to a stroke (cerebrovascular accident / CVA). The demand for oxygen by the brain is higher than most other organs and even a few seconds without oxygen to the brain will lead to various, often serious symptoms. This is due to the tissue injury associated with low oxygen availability (ischemia). Within minutes, brain tissue will die. A blood clot causes an ischemic stroke, and may be further classified as thrombotic when the clot forms in the artery, or embolic when it travels from elsewhere.

A common site outside of the cranial cavity where a blood clot impairs the blood supply to the brain is the neck arteries (carotid arteries). This is often associated with narrowing due to atherosclerosis. Clots further exacerbate the obstruction and may cause an almost complete blockage. This may be preceded by attacks of low oxygen availability known as a transient ischemic attack (TIA). These episodes causes symptoms exactly as a stroke but is short-lived (usually 5 minutes but sometimes up to an hour or even 24 hours). It is also known as a pre-stroke or mini-stroke and is a warning sign of an impending stroke.

There are lots of asthma triggers which come under the category of allergens and irritants which are usually found in the stuff and floors of home like carpets, rugs, curtains etc. Most common triggers include dust mites, mold, pet dander, rodents, pollen, tobacco smoke, sharp smells of perfumes etc. So it is must to make house an asthma healthy zone to avoid its symptoms. Merck launched a “Build Smart, Breathe Easier” campaign to educate people about the magnitude of “asthma-healthy home”.

To make this campaign a great success, Merck joined with Habitat for Humanity, the Asthma and Allergy Foundation of America (AAFA) and HGTV personality and carpenter Carter Oosterhouse to construct four houses in order to help the people having low incomes.

Dr. Gokul Gopalan, regional director of Medical Affairs, Respiratory, Merck. “We are pleased to partner with these experts to build homes with asthma-healthy features and educate about the importance of a healthy indoor environment, coupled with proper asthma management, Build Smart, Breathe Easier reinforces Merck’s ongoing commitment to educate people about their asthma and provide appropriate treatment options to physicians and their patients.”

It is very important to create and maintain asthma healthy home, Carter Oosterhouse from HGTV said “A house built with materials that are easy to clean and less likely to contain irritants, such as hard-surface floors or non-toxic paint, may have a positive impact on a family, especially one dealing with asthma, I am excited to be a part of this program which will help build sustainable homes with asthma-friendly features in partnership with low income families and will also educate about simple ways to try to reduce and avoid common household asthma triggers.”

What is Rosacea?

Rosacea is a common skin ailment that results in severe redness of central part of the face like cheeks, nose and forehead. Although rarely, it may also affect other body parts like neck, chest, ears and scalp. It is not a very harmful disease to be scared of; however, if it affects your eyes, you must consult a doctor immediately.

Rosacea Causes

The Demodex folliculorum, better known as the “hair follicle mite”, has a role to play in Rosacea, though it is not yet completely proven. Research shows that Rosacea patients have more number of these mites on their skin than others who don’t suffer from this problem. Another bacteria, Helicobacter pylori, which causes stomach ulcers, is also linked to Rosacea in that it affects the intestines of people and this brings out the symptoms on the skin.

Rosacea Victims

Doctors suggest that Rosacea can affect both men and women, normally after 30 years of age. People who blush a lot and have fair skin are most likely to be attacked by Rosacea. Those who are exposed to extreme temperatures, severe sunburn, strenuous activities, anxiety and sudden movement from warm to cold environment or vice versa, are more prone to this disease as their face gets flushed out very easily. People who consume a lot of alcohol, caffeine-rich foods and beverages, spicy foods and foods that contain high level of histamine (such as red wine, yogurt and beer) indirectly attract Rosacea.

Rosacea Symptoms

Rosacea has some resemblance with the more common “acne” but in case of the former, the blood vessels swell up and become more prominent like a spider web on the face. Other symptoms are:- A “bulbous” or thick nose, mostly seen in case of men. Red, acne-like eruptions on the skin that may be filled with pus. Burning sensation or itching on the face. Red and watery eyes for most of the time.

Rosacea Related problems

Often, people fail to differentiate between common acne and Rosacea, since the way it affects the skin is quite similar. As a result, people leave it unattended and let the disease do the damage. Besides physically affecting the skin of people, Rosacea also causes mental harm to patients as it lowers their self confidence and makes them reluctant to socialize due to their looks.

Rosacea Treatment

Doctors prescribe topical antibiotic like Metrogel and sulfacetamide or even oral medicines to bring the redness in control. Also, broad-spectrum sunscreen lotions that provide good protection from the harmful UV rays of the sun are a good way to prevent the initial attack of Rosacea. For those who develop a bulbous nose or get acute acne and redness, consultation with a dermatologist for cosmetic surgery is the last resort.