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Drugs administered by routine parenteral administration are distributed throughout the body and reach nontarget (normal/healthy) organs/tissues leading to possible toxic side effects and low efficacy of treatment sleep aid for pregnant mothers generic modafinil 100 mg with amex. As a result, only small fraction of the administered drug dosage will reach the target (diseased) organ or tissues. Targeted drug delivery62 aims to overcome limitations associated with routine drug administration by delivering drugs specifically to diseased cells and tissues while not exposing healthy tissues. Ensuring minimal drug loss during the transit to the target site, protecting the drug from metabolism and premature clearance, retaining the drug at the target site for desired period of time, facilitating the drug transport in to the cell, and delivering the drug to the appropriate intracellular target site are other requirements of targeted drug delivery. Last but not least, these targeted drug delivery systems should be biocompatible, biodegradable, and nonantigenic. Moreover, this substance should be efficacious in a concentration that is harmless for patients. While screening trivalent arsenic compounds for their potency on Treponema pallidum, the causative agent for syphilis, he discovered Salvarsan (magic bullet), which killed syphilis organisms in most cases without killing the host. Although the concept of the magic bullet was introduced 100 years ago, the challenge of making drugs with Drug targeting approaches are grouped in to two major categories: (a) active targeting and (b) passive targeting. These cell surface targets are distinguished in to two categories: noninternalizing and internalizing. In noninternalizing systems, the drug conjugate is cleaved extracellularly, whereas in internalizing systems drug is cleaved intracellularly after endocytosis. The delivery system has three components: (a) drug, (b) carrier, and (c) the homing device or the targeting moiety. The drug release in most of the prodrugs is accomplished by conjugating the drug to the carrier through a spacer that incorporates a predetermined breaking point, which allows the drug to be released at the cellular target site. It is achieved by incorporating linkages sensitive to enzymatic cleavage, acidic pH, hypoxia, or thiol-exchange reactions. Several cell-specific receptors are expressed under physiological conditions, which are specific to ligands and therefore could be exploited for targeting. Examples include (a) antigenic sites on pathogens (bacteria, viruses, and parasites); (b) infected cells expressing specific antigens; and (c) tumor-associated antigens/receptors. Most mAbs belong to the immunoglobulins of the IgG class, which is smallest in size but most abundant antibody found in all biological fluids. Several standard chemotherapeutic agents including antifolates, vinca alkaloids, or anthracyclines have been conjugated to mAbs mostly through cathepsin-B sensitive peptide linker or disulfide bond. It was found that these antibody conjugates indeed have selectivity toward the cells that expresses the respective antigens. These conjugates, however, failed in clinical trials because the mAbs were of murine origin and invoked immune responses. The problem of immunogenicity was resolved by the development of chimeric and humanized antibodies that do not carry murine sequences. Active targeting is achieved by binding drugs to ligands that display high affinity for a particular receptor.
Syndromes
Furthermore insomnia zyrtec modafinil 100 mg order online, since the number of intraductal photographs with pathologic correlates is still small, the learning curve also includes building up your own personal repertoire of pathologic correlates. Equipment prices continue to fall and the technology is becoming more affordable as multiple manufacturers of submillimeter endoscopes worldwide are adapting their technologies to breast duct applications. A number of intraductal biopsy tools are beginning to appear to allow biopsy through these submillimeter scopes. Pathologists Chapter 5 Breast Ductoscopy 91 will have to modify their approach to such specimens to try to give meaningful and precise answers with such small tissue samples. Its role in the management of early-stage breast cancer is evolving but clearly directs us toward the goal of anatomic resection of proliferative disease instead of the more traditional nonanatomic lumpectomy. Perhaps the greatest importance however of ductoscopy is the ready access to the ductal epithelium in vivo for research purposes. Just as the polyp model of colon cancer with its sequence of genetic alterations, the ability to visualize, and repeatedly sample and monitor chemoprevention efforts will direct us in unlocking the secrets of breast cancer carcinogenesis and prevention, development of molecular markers might even allow us to screen for the precancerous stages and prevent breast cancer instead of waiting till there is an invasive cancer in the majority of patients. Fiberoptic ductoscopy of the breast: A new diagnostic procedure for nipple discharge. Nipple discharge disorders: Current diagnostic management and the role of fiber ductoscopy. A utility of ductography and fiberoptic ductoscopy for patients with nipple discharge. New diagnostic approach to intracystic lesions of the breast by fiberoptic ductoscopy. These modalities should be used in conjunction with annual mammographic examinations for the detection of breast cancer. A wide spectrum of benign, potentially malignant, and malignant lesions of the breast may present as a palpable nodule or lump in the breast. When patients present with a new palpable lesion or a new lesion is detected on physical examination by a health care provider, further characterization of the lesion is warranted. Many but not all palpable lesions are detectable and assessable on breast imaging studies. This approach allows detailed multidisciplinary treatment planning for patients who have breast cancer and potentially limits the number of operative interventions ultimately required. At present, we perform excisional biopsy of palpable breast lesions to the following five indications: 1. Palpable lesions that cannot be detected on breast imaging studies Discordance between percutaneous biopsy results and imaging studies Lesions strongly suspected to be consistent with fibroadenomas in younger women Lesions in an unfavorable position for percutaneous biopsy (near chest wall or near an implant) 5. Information regarding the details of a palpable lesion includes size, rate of change in size, location in the breast, texture, method of detection (patient or other health care provider), and associated symptoms.
The Coulter counter has been used to advantage in the pharmaceutical sciences to study particle growth and dissolution20 insomnia 38 weeks pregnant order modafinil 200 mg line,21 and the effect of antibacterial agents on the growth of microorganisms. Samples of spectinomycin hydrochloride and a micronized steroid were subjected to particle-size analysis together with polystyrene spheres of 2. The powders showed log-normal distributions and were well characterized by geometric volume mean diameters and geometric standard deviations. Accurate particle sizes were obtained between 2 and 80 m diameter with a precision of about 0. The authors concluded that the automated Coulter counter was quite satisfactory for quality control of pharmaceutical powders. The Coulter particle counter was used by Ismail and Tawashi24 to obtain size distributions of the min- eral part of human kidney (urinary) stones and to determine whether there is a critical size range for stone formation. The study provided a better understanding of the clustering process and the packing of the mineral components of renal stones. Beckman Coulter also manufactures a submicron-particle sizing instrument, the Beckman Coulter Model N5, for analyzing particles in the size range of 0. By the use of photon correlation spectroscopy, the instrument senses the Brownian motion of the particles in suspension. A laser beam passes through the sample and a sensor detects the light scattered by the particles undergoing Brownian motion. The Beckman Coulter Model N5 instrument provides not only particle-size and size distribution data but also molecular weights and diffusion coefficients. Submicron size determination is important in pharmacy in the analysis of microemulsions, pigments and dyes, colloids, micelles and solubilized systems, liposomes, and microparticles. About one fifth of the samples showed a considerable number of particles of sizes greater than 20 m in diameter. The particles were identified as textile fibers, cellulose, plastic material, and contaminants from the manufacturing and packaging processes, such as pieces of rubber and bits of metal. Because of their number, size, shape, surface properties, and chemical nature, these contaminants can cause vascular occlusions and inflammatory, neoplastic, and allergic reactions. Its surface properties and chemical structure as a film coating polymer were reviewed by Davies et al. Carli and Motta28 investigated the use of microcomputerized mercury porosimetry to obtain particle-size and surface area distributions of pharmaceutical powders. Mercury porosimetry gives the volume of the pores of a powder, which is penetrated by mercury at each successive pressure; the pore volume is converted in to a pore-size distribution.
Rest insomnia zanaflex 100 mg modafinil amex, increased fluid intake, and more frequent suckling of the infant are additional important components of treatment to help clear the ductal obstruction. Diagnostic ultrasound should be obtained if there is any suspicion of abscess at presentation or if rapid clinical improvement does not occur with antibiotic therapy. For unifocal or multifocal abscesses in a stable patient, percutaneous aspiration should be attempted. Abscesses smaller than 3 cm in diameter can be simply aspirated, whereas larger abscesses can be approached either with aspiration or with percutaneous catheter drainage. Ultrasound guidance should be used in order to achieve maximal drainage of pus from the abscess, and the aspirate should be sent for culture with microbial sensitivities to tailor antimicrobial treatment. Although the responsible organism is usually Staph aureus, resistant strains are increasing in the community and non-Staphylococcal species can be identified on occasion. Dicloxacillin is safe for the suckling infant, but if another antibiotic is chosen because of an unusual or resistant bacteria, safety for the infant should be addressed since the medication and/or metabolites are routinely transmitted via the breast milk. Antibiotics are prescribed as mentioned earlier, and the patient returns for repeat ultrasound and reaspiration every other day until no fluid remains in the cavity. For larger abscesses, a small percutaneous closed suction drain can be placed as an alternative approach to serial aspiration. Any of the following constitutes failure of nonoperative treatment and is an indication for surgical drainage: worsening systemic illness despite aspiration and antibiotics, abscess cavity does not progressively diminish in size, or local progression evidenced by skin necrosis or other changes. Other indications for initial operative drainage are very large abscess size, complicated and extensive pattern of infected fluid collections throughout the breast, and inability to obtain adequate drainage of infected material with a percutaneous approach. If the patient does not improve within 36 hours, then breast ultrasound is indicated to look for a fluid collection defining the presence of an abscess. Ultrasound showed a fluid collection underlying the site of erythema, connected with a larger fluid collection occupying the entire subareolar space, and having an estimated size greater than 10 cm. Because of large size and chronicity of symptoms, decision was made for surgical drainage. A radially oriented incision was made in the medial breast, 160 mL of pus was drained, abscess wall was debrided, and tissue sent for biopsy, which was benign. In cases of documented lactational abscess, consultation with a lactation consultant is appropriate preoperatively to help manage ongoing lactation postoperatively and to ensure proper lactation techniques to help correct problems that could predispose the contralateral breast similarly to mastitis and abscess. If the patient wishes to stop nursing, gradual rather than immediate cessation of lactation is preferred because of the ensuing engorgement that occurs with abrupt cessation of lactation, magnifying postoperative pain and possibly increasing the risk of milk fistula. If the infectious process is severe with extensive tissue necrosis, consultation with a plastic surgeon is advisable to help plan the surgical approach and optimize the cosmetic result.
In other studies insomnia tv discount modafinil 200 mg overnight delivery, the incidence of procedure-related paraplegia in patients with open repair is high, from 2. One technique used in open repair to avoid paraplegia is some method of aortic bypass such as the external heparin-bonded shunt. However, Whitson and colleagues74 have reported that distal aortic perfusion in traumatic aortic injuries is not necessary to avoid perioperative paraplegia. In patients discovered to have a false aneurysm, frequently seen by the presence of calcification in the wall of the aneurysm weeks to years after the traumatic episode, a decision to repair the pseudoaneurysm is difficult. In an asymptomatic patient, the possibility of operative mortality and morbidity must be balanced by the knowledge that symptoms and late rupture are not unusual. If the missile is in tissue, it can be encapsulated by fibrous tissue and remain inert for many years. If the foreign body lodges in a right heart chamber or systemic vein, it can embolize distally in the right heart or in to the branches of the pulmonary artery. If it is in a pulmonary vein or left heart chamber, it can embolize distally and come to rest in a peripheral artery distant from the heart. Foreign bodies that enter and are retained in the pericardial space can result in recurrent pericarditis. In such cases, X-ray examination of the entire body to locate the missile is recommended. The presence of a retained foreign body that is not infected raises the question of whether it should be removed. On follow-up a number of patients had complications with embolization and one with erosion of a bronchus with subsequent pneumonectomy. Thirty of the patients had neurasthenic problems with the knowledge of the presence of an intracardiac foreign body. The authors concluded that if the foreign body was 1 cm or greater in diameter, then the psychological burden of the awareness of an intracardiac foreign body warranted its removal. Finally, percutaneous catheter placement in to the subclavian and internal jugular veins has proven to be complicated by numerous problems including hemopneumothorax and inadvertent passage in to or laceration of subclavian and carotid arteries, at times leading to exsanguinations. With emerging interventional therapeutic techniques such as percutaneous valvuloplasty and pulmonic and aortic valve placement, device closure of intracardiac septal defects and embolization of shunts and fistulae, more reports of iatrogenic cardiovascular injury are expected. Percutaneous closure of postoperative and post-traumatic ventricular septal defects. Traumatic aortic dissection and coronary fistula treated with transcatheter management. With needles placed percutaneously and guide wires and catheters passed over them, there are many reports of arterial and venous laceration requiring operative repair, thrombosis, A-V fistulae, false aneurysms and lost catheters. Repair of flail leaflet of the tricuspid valve by a simple cusp remodeling technique. Delayed presentation of injury to the sinus of valsalva with aortic regurgitation resulting from penetrating cardiac wounds.
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However insomnia first trimester generic 200 mg modafinil, further evaluation, including noninvasive testing, may be recommended so that the risk of sexual activity may be more judiciously investigated (Table 25-1). However, patients at low risk may safely engage in sexual activity and may be treated for erectile dysfunction. First-line therapies should be considered on an individual basis, and it is recommended that patients be reassessed every 6-12 months for change in clinical status. A full history and physical as well as screening laboratory tests provide data necessary for proper evaluation of risk. All cardiovascular risk factors should be assessed and appropriately managed during this initial evaluation. While there is insufficient data to encompass all cardiac diseases, most patients can be stratified in to one of three major graded categories of cardiac risk defined by the Second Princeton Consensus: lowrisk, intermediate risk, and high risk (Tables 25-1 to 25-3). Proper management of these diseases may allow patients to be restratified in to the low risk group. High risk patients have sufficiently severe cardiac conditions and are at significant risk of cardiac symptoms and complications from any physical activity, including sexual activity. Age Hypertension Diabetes mellitus Obesity Cigarette smoking Dyslipidemia Sedentary lifestyle Male, postmenopausal female* Physiology of Sexual Activity the physiologic effect of sexual arousal and sexual activity is somewhat variable. However, sexual activity is associated with sympathetic activation, which may elevate blood pressure and may induce arrhythmias ranging from premature complexes to ventricular tachyarrhythmias. The physiologic response may be greater than with exercises of similar metabolic demand as sexual arousal may also augment the sympathetic response of sexual activity. While cardiac complications of sexual activity are rare, it is critical to assess cardiac risk prior to treating erectile dysfunction due to the consequences of sexual activity on cardiac physiology. Cardiologic evaluation, testing, and management should be prioritized before recommending resumption of any sexual activity. Patients should be strongly encouraged to abstain from sexual activity until cardiac condition has been stabilized and their healthcare provider deems the risk to be appropriately low. There are many mechanisms that may contribute to this relationship, including atherosclerosis, loss of exercise tolerance, concomitant depression, altered endothelial function, and medications commonly used in treatment of heart failure. In particular, beta-adrenergic blockers, digoxin, and diuretics have all been associated with sexual dysfunction. Thus, careful counseling should be done in all patients who are being treated with these agents. Even in the low risk heart failure population, addressing sexual function and frequent counseling is critical to ensure compliance with medications that have shown to improve cardiovascular outcomes. Regardless of cardiac risk, all patients with erectile dysfunction require close monitoring and follow up of cardiovascular disease and risks. Erectile dysfunction shares risk factors with atherosclerotic disease, and it may be the sole symptom in patients with otherwise subclinical cardiovascular disease.
Breast reduction is best performed as a secondary procedure after flap reconstruction or at the time of permanent implant placement after tissue expander reconstruction sleep aid target discount modafinil 200 mg otc. Breast reduction techniques all result in some internal breast scarring postoperatively. When breast reduction is performed, it is important to choose a technique that has a low risk for fat necrosis. When fat necrosis occurs within the breast, it can pose diagnostic problems, usually requiring biopsy. Liposuction is avoided in breast reduction due to potential distortion of the internal architecture of the breast, which may make future mammographic interpretation more difficult. This is particularly important in the group of patients who have had cancer in the other breast. Mastopexy Mastopexy is often required when significant ptosis exists in the contralateral breast since breast symmetry is the goal of reconstruction. Mastopexy, similar to breast reduction, is best performed as a secondary procedure. Available mastopexy procedures either reshape the skin or internally reshape the breast mound. Internal architectural distortion should be minimized in these patients if possible. It is best to avoid mastopexy techniques that extensively reshape the breast gland. In general, long-term results have been very similar for both internal reshaping procedures and dermal procedures. Breast Augmentation Usually breast augmentation is useful in small-breasted women who have undergone implant reconstruction and need additional upper breast fullness in the normal breast to achieve symmetry. Augmentation will always interfere with future mammograms, making it difficult to visualize all of the breast tissue when an underlying implant is present. When the implant is small, placed subpectorally, and remains soft, the degree of mammographic distortion is minimal. The use of saline implants placed underneath the pectoralis muscle has significantly reduced the incidence of capsular contracture and subsequent firmness of the breast. When augmentation is being considered, carefully documented consultations with the oncologic surgeon and mammographer are important. Augmentation is best performed at the time of final implant placement to achieve best symmetry.
Physical exam findings: Physical examination should include a search for xanthomas (cholesterol deposits) in hands insomnia 1995 modafinil 100 mg order free shipping, elbows, knees, and Achilles tendons, xanthelasmas (cholesterol deposits in palpebral fissures), corneal arcus, and corneal opacification. Laboratory testing: A standard serum lipid profile is generally sufficient for a diagnosis of lipoprotein disorders and is recommended at least every 5 years in all adults over 20 years of age. The lipid profile should be performed after 9-12 hours of fasting to minimize the influence of postprandial hypertriglyceridemia. Thus, serum lipids should be measured several weeks after such stressors to provide more accurate values. Other tests that are recommended to exclude secondary causes of dyslipidemia include thyroid-stimulating hormone, creatinine, and liver function tests. In higher risk patients such as those with established atherosclerotic disease or diabetes, concomitant early initiation of pharmacologic treatment is warranted. The major sources of dietary cholesterol are egg yolks, animal fats, and meat, and saturated fatty acids are butter fat, animal fat, and tropical oils. In addition, foods rich in complex carbohydrates such as whole grains, fruits, and vegetables are preferred to those containing simple carbohydrates, especially for those with elevated triglyceride levels and insulin resistance. In a patient with morbid obesity, bariatric surgery and pharmacologic intervention such as orlistat, and sibutramine may be indicated. Pharmacologic Treatment the six major classes of lipid lowering medications are: 1. The impact of various lipid-lowering medications on lipid levels is illustrated in Table 20-5. This class of medications is generally very safe, with the most commonly encountered side effects of myopathy and elevation of liver function test, both of which are reversible with discontinuation of statins. In a patient with predisposing conditions to severe myopathy (Table 20-6), statins should be used with caution, or the dose modified, as the risk of myopathy is increased. Details of the key clinical trials with primary outcomes and risk reduction are summarized in Table 20-7. The benefits of statins were seen in most if not all subgroups, including men and women, older and younger subjects, smokers and nonsmokers, hypertensive and normotensive subjects, and diabetic and nondiabetic subjects. It is important to note that these trials excluded high risk subjects such as those with symptomatic heart failure and those with low ejection fraction <25%. After 5 years of therapy, simvastatin-treated subjects had a 13% reduction in mortality and 25% reduction in first vascular event. Bile Acid Sequestrants, or Resins Bile acid sequestrants, also known as bile acid resins, are a class of medication that includes cholestyramine, colestipol, and colesevelam. These agents inhibit intestinal absorption of bile acids, reducing their enterohepatic recirculation. Intolerance to side effects, which include bloating, constipation, nausea, and esophageal reflux, is common with older preparations but less frequent with colesevelam. If given concomitantly, bile acid sequestrants can interfere with absorption of vitamin K, digoxin, warfarin, thyroxine, statins, and diuretics. Despite these side effects and drug interactions, sequestrants are useful adjunctive agent to statins or nicotinic acid in treatment of severe hyperlipidemia or as montherapy in statinintolerant patients with elevated cholesterol levels.
A flap of overlying skin flap and subcutaneous tissue medial to the vertebral border of the scapula is elevated sleep aid remedies purchase 100 mg modafinil with mastercard, extending it from the inferior angle of the scapula to the clavicle. The scapula is then pulled away from the chest wall with a retractor, and the levator scapulae and rhomboideus minor and major muscles are divided. The dissection is continued around the inferior angle of the scapula where the latissimus dorsi muscle is divided. Ligation of the superficial cervical and descending scapular vessels is then undertaken. The superior digitations of the serratus anterior muscle are divided close to the superior angle of the scapula followed by the remaining insertions of the serratus anterior muscle along the vertebral border of the scapula. The clavicle and subclavius muscle are divided at the medial end of the bone, allowing the upper extremity to fall anteriorly. The neurovascular bundle is identified close to the superior digitations of the serratus anterior muscle. As the dissection is carried deeper, the brachial plexus is encountered in addition to the subclavian artery and vein. The cords of the brachial plexus are ligated and divided close to the spine with 0-silk sutures. The subclavian artery and vein should be dissected free and doubly ligated with 0-silk sutures prior to transecting the vessels. The omohyoid muscle is divided, followed by ligation and division of the suprascapular vessels and the external jugular vein. The anterior incision is then created at the middle of the clavicle and extended inferiorly just lateral to but parallel with the deltopectoral groove. The anterior incision is extended to meet the posterior incision at the inferior angle of the scapula. The pectoralis minor muscle is divided from its origin at the third to the fifth ribs. The skin flaps are then closed after hemostasis and placement of closed-suction drains. Care should be taken to place the skin graft over a bed of viable muscle or healthy subcutaneous tissue. Operative Technique for the Anterior Approach the upper aspect of the incision is begun at the lateral border of the sternocleidomastoid muscle and extended laterally along the anterior aspect of the clavicle, across the acromioclavicular joint, over the superior aspect of the shoulder to the spine of the scapula. The incision is then extended across the axilla to join the posterior incision at the angle of the scapula. Dissection is carried toward the clavicle where the pectoralis major muscle is divided at its clavicular origin. Dissection then proceeds through the deep fascia over the superior border of the clavicle. The clavicle is divided at the lateral border of the sternocleidomastoid muscle and removed by separating the acromioclavicular joint. The insertion of the pectoralis major muscle is released from the humerus and the origin of the pectoralis minor separated from the coracoid process.
Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy insomnia uws buy modafinil 100 mg with mastercard. Patients falling outside of these parameters can be treated on an individualized basis-always in consultation with the radiation oncologist. Individual Brachytherapy Devices Balloon Devices MammoSite Balloon the first generation of MammoSite balloon was approved by the U. It comes in two spherical sizes-4 to 5 cm and 5 to 6 cm-as well as a 5 cm elliptical size. The main advantages of the MammoSite balloon are the comfort of the soft silicone and the familiarity of the device (it has been available the longest of any of the brachytherapy devices). The main disadvantages are the need for a minimum of 5 mm of skin-to-cavity distance (preferably 7 mm) and the soft balloon may not expand symmetrically, causing the central treatment lumen to be offset and therefore unusable. A second-generation device made of polyurethane is now available that overcomes the symmetry issue but not the skin spacing problem. These multiple catheters allow the treatment plan to more precisely tailor the prescription dose to the cavity avoiding excess dose to the skin and chest wall. It comes in two sizes-a 4- to 5-cm diameter balloon and a 5 to 6-cm diameter balloon. It looks very similar to the MammoSite with similar insertion methods; however, the multiple catheters allow the treatment plan to more precisely tailor the dose to the cavity, avoiding normal structures such as heart, lung, rib, and skin (thus allowing a narrower skin-to-cavity distance). In addition, the device has suction parts at each end of the balloon to aspirate fluid and air from the cavity. The main disadvantage of Contura is the stiffness of the catheters, which can be uncomfortable to some patients. The balloon is filled with a combination of saline and a small amount of contrast such as Isovue. By the end of 2009, approximately 6000 devices will have been placed and only short-term data are available for this device. The company has begun a registry trial with a targeted accrual of approximately 400 patients. It comes in 6-mini, 6, 8, or 10 catheters depending on the size of the lumpectomy cavity. The multiple catheters allow the treatment plan to more precisely tailor the dose to the cavity, avoiding normal structures such as heart, lung, rib, and skin (thus allowing a narrower skin-to-cavity distance). By the end of 2009, approximately 3000 patients will have been treated with this device and only short-term treatment data are available.
Myxir, 57 years: Pu Introduction It is not uncommon to have residual contour irregularities or asymmetries between breasts after breast reconstruction, whether implant or autologous.
Pedar, 25 years: The amount of emission can be measured either in terms of its quantum yield (the number of photons emitted divided by the number absorbed) or by simple intensity changes at a fixed wavelength.
Ayitos, 52 years: The impact on postsurgical treatment of sentinel lymph node biopsy of internal mammary lymph nodes in patients with breast cancer.
Ali, 63 years: The skin design can be up to 30 cm in length and 10 to 12 cm in width and still allow closure of the buttock without tension.
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