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5 Exercises to Get a V-Line Shape Girls Go Crazy Over

If you are tired of exhausting your body at the gym without seeing any results, then this article is for you. But you should remember, that some people are more genetically predisposed and, for them, the process is shorter and easier.

Bright Side found 5 exercises that can help you get a perfect V-Cut. And there’s an impressive bonus at the end of the article.

Before you start training

First of all, lower your body fat. You would be wasting your time and effort by doing the same exercises if you are not lean. And, in this case, there is only one secret: you must eat fewer calories than you burn. Nothing more. And yes, it is not easy.

Second, sleep more. Studies have proven that the more you sleep, the more of the growth hormone is released. Exactly this hormone is what you need to get a perfect body and to control your fat level. So it’s better not to stay up too late at night in front of your computer or TV.

After you have prepared your body, it’s time to work out.

1. Hanging leg raises

Raise your legs until your thighs make a 90° angle. Knees should be bent a bit. Stay in this position for a second and then lower your legs.

You can repeat this exercise 3 times (10-20 reps) or until you feel the burn.

2. Reverse crunches

Lay down on your back with your legs raised and knees bent. Stretch your arms out with your palms touching the ground. Let your legs drop down at their own speed. Your knees should come toward your chest.

Do 3 sets of 20 reps.

3. Lying leg raises

For this exercise, lay down. Your back should be flat on the floor, hands on the floor at your sides, and your feet should be together. Try to keep your knees as straight as you can and lift your feet up.

Do 3 sets of 15-20 reps.

4. Ab wheel

For this exercise, hold the ab roller with both hands and place it on the floor in front of you.

Slowly stretch your body by rolling the ab roller out in front of you. Don’t touch the floor and try to get down as far as you can. Then, pull yourself back.

Do 3-4 sets of 10-15 reps.

5. Ab V Hold

Do this exercise at the end of the routine. Form the letter V with your body. You need to stay in this position for at least 30 seconds to 2 minutes.

Bonus: This is how a body can transform when following a healthy diet and working out:

Have you tried any of these exercises? Share your thoughts with us in the comments section below!

The Most Effective Exercises to Build a V-Shape Near the Waist | Woman

i Goodshoot/Goodshoot/Getty Images

A V-shape near the waist is the hallmark of a very toned, low-fat body. Not everyone can get this coveted look, and your body’s ability to create a V-shape depends on how quickly you lose fat, how effectively you build muscle and your overall body shape. With lots of hard work, though, you may be able to build a V-shape.

Challenges

Simply toning your muscles won’t result in a V-shape, because this fitness achievement is the result of very low body fat in the lower abdominal muscles. According to ScienceDaily, women have between six and 11 percent more body fat than men, and this can make it challenging to shed the fat you need to get a V-shape. It can take months of work and lots of intense exercise, and even then, your body type just might not be right for V-shaped abs.

Fat-Reducing Exercises

It’s easy to get fixated on doing abdominal exercises, but you’ll have to shed fat before the muscles that result from your work will be visible. To lose weight, you might need as many as 300 minutes of cardiovascular exercise per week, according to the Mayo Clinic. You’ll burn more calories with intense cardiovascular exercise such as running or speed swimming, but for a less intense cardio workout, try water aerobics, walking or dancing.

Back Exercises

Strengthening your back — particularly the lower portion — can help you slim down your waist, and will make most other exercises easier. Lie on your back with your knees bent and feet flat, then grab one knee and pull it to your chest. Switch sides, pulling the other knee up to your chest, then pull both knees up at the same time. Hold for 15 to 30 seconds each time you pull a knee to your chest. Next, try squatting against the wall. Position your back up against the wall, then walk your legs out so your knees are bent as if you are sitting in a chair. Hold for 15 seconds and repeat five to 10 times.

How to Get a V-Cut Stomach

A V-cut stomach requires time in the gym and a well-managed diet.

Image Credit: iammotos/iStock/GettyImages

Six-pack abs are arguably the most desired physical feature for fitness enthusiasts. And except for the rare case, six-pack abs are visual proof of dedicated exercise and sound nutrition. But there’s one addition to the classic six-pack that takes your body to the next level: A V-cut stomach — the hallmark of a lean, athletic physique.

To build it, you’ll need to dedicate your nutrition and stay in a caloric deficit. Then, you’ll need to exercise with compound exercises, as well as specific ab work, to add the finishing touches. With consistent hard work, a V-cut stomach can be yours.

What Is a V-Cut Stomach?

The V-cut is the product of low body fat and dense ligaments that mark the barrier of your rectus abdominis, or your six-pack, muscles. To optimize your ab development and get a V-cut stomach, you need very low body fat, often between 4 and 7 percent, and well-developed, muscular abs.

How to Lower Your Body Fat

Lowering your body fat requires a dual attack with both your diet and exercise routine. Still, the cliche that “abs are made in the kitchen” rings true. Your best bet for fat loss is eating fewer calories than you’re burning. Track your calories with an app such as MyPlate.

Counting calories alone isn’t enough if you don’t focus on healthier food choices. A focus on high-quality foods, while decreasing consumption of lower-quality foods, is an important factor in helping you consume fewer calories.

Therefore, make it your focus to eat more unrefined and minimally processed foods. Lean protein, such as fish and chicken; fruits and vegetables; and healthy fats, like raw nuts, make up most meals. The, decrease the amount of processed food you eat, including sweetened drinks, fried foods and refined snacks.

Exercise for Fat Loss

Resistance training should emphasize compound lifts, like dead lifts, squats, pullups and lunges, as the foundation of your training. Training for strength with big movements stimulates the largest muscles in your body to release anabolic hormones, like testosterone and growth hormone, both of which aid in burning body fat and stimulating muscle growth.

Then according to the American College of Sports Medicine, as much as 150 to 250 minutes per week of moderate-intensity physical activity is necessary for weight loss. That equates to three resistance training workouts of 45 minutes and three 30-minute aerobic workouts, such as biking, per week.

Read more: The Cardio Abs Workout

Direct Ab Training

To maximize the definition and development of your V-cut stomach, it’s important to train your abs. Stronger, more muscular abs create deeper separations between the two halves of the rectus abdominis muscle, helping your abs remain visible even when your body fat is a higher.

Perform one rollout variation and the hanging leg raise twice per week during your training to build dense, separated abdominal V-lines.

1. Stability Ball Rollout

HOW TO DO IT: Begin by kneeling with your elbows resting on a stability ball. Brace your abs as if you were doing a plank; then slowly extend your arms in front of your torso.

Roll out slowly until you feel the stretch in your abs, pause for one second and then roll the ball back in. Do two sets of 10 reps on the stability ball rollout. Once stability ball rollouts become easy, move on to the next exercise.

2. Ab Wheel Rollout

Ab wheel rollouts are an absolute killer for ab development. Plus, they force you to resist the arching of your lower back while also training your lats, shoulders and triceps.

HOW TO DO IT: Kneel down, holding the handles of the wheel with your arms locked out beneath your shoulders. Brace your abs and roll out as far as possible; then roll back without shifting your hips or arching your lower back.

Start small on the ab wheel with two or three sets of six to eight reps. As you improve, add two or three reps per week up to 15 reps. Then add a third set.

3. Hanging Leg Raise

The hanging leg raise is an excellent exercise for targeting the lower portion of your rectus abdominis. Unlike crunches, which focus on stimulating the upper abdominals, leg raises force the hips and lower portion of the abdominals to flex and tilt the pelvis.

HOW TO DO IT: With a double-overhand grip, hang from a pullup bar with your elbows slightly bent and shoulders retracted. Bring your legs up past 90 degrees, rolling your hips and forming an “L” shape with your body.

Pause at the top for one second; then slowly lower your legs under control to the full hanging position. If you struggle with the hanging leg raise, start by keeping your knees bent on all reps, slowly straightening your legs as you become stronger. Perform three sets of 10 to 15 reps of the hanging leg raise.

Read more: Strength Training for Losing Weight

How to get an Adonis belt: Home and gym exercises

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The Adonis belt – sometimes called Apollo’s belt – refers to two V-shaped muscular grooves on the abdominal muscles alongside the hips.

This feature of the abdominal muscles takes its name from Adonis, the legendary god of fertility, youth, and beauty.

The grooves of the Adonis belt are, in fact, ligaments, not muscles. This means that cultivating an Adonis belt requires the loss of fat, not the creation of muscle.

Share on PinterestThe two shallow grooves of the adonis belt are ligaments rather than muscles.

The Adonis belt is a thick band of connective tissue that runs through the external oblique abdominal muscles, across the groin, and into the front portion of the iliac spine.

People who are relatively physically weak may have a visible inguinal ligament, while powerful and fit people might not. Instead, the Adonis belt is associated with body fat.

People with less body fat are more likely to have a visible Adonis belt.

This means a person could spend several hours each day on abdominal exercises and still not develop an Adonis belt or any other visible sign of abdominal strength.

For a person to have visible abdominal muscles, their percentage of body fat needs to be below 15 percent. For the Adonis belt to make an appearance, body fat might need to be as low as 6-13 percent.

To get an Adonis belt, one might think it makes sense to exercise the abdominal and hip muscles.

The problem is that this strategy does not work. The notion that it is possible to reduce fat in a particular area of the body with targeted exercises is a myth.

Strengthening a muscle to increase its size will not make it visible under the fat. Both diet and exercise play a role in reducing body fat.

Because genetics can affect body fat percentage, it is easier for some people to develop an Adonis belt than others.

Dieting for an Adonis belt

Eating fewer calories than the body needs for energy can support fat loss. That means cutting down on total caloric intake. It can also help to cut back on sweetened snacks and carbohydrates.

Some foods also require more energy to burn than others. Protein is one such food. It can also promote feelings of fullness, making it an ideal choice for people trying to avoid overeating.

And because protein is vital for muscle development, increasing protein intake can support healthy, visible abdominal muscles.

Exercises for reducing body fat

Activities that involve large groups of muscles and which get the heart pumping burn more fat than targeted exercises such as crunches and sit-ups.

Try intensive cardiovascular exercises such as:

  • running
  • swimming
  • jumping rope
  • punching-bag workouts
  • sprints
  • cardio-heavy sports, such as football, tennis, or other athletics

The longer the exercise is performed and the more exhausting it feels, the more calories – and therefore the more fat – it will burn.

Building muscle can help the body burn more calories, and therefore shed more fat. Strengthening the muscles surrounding the inguinal ligament can help the area look more defined, and support fat burning. Try the following:

Planks

Planks strengthen and stabilize the back and abdominal muscles. Lie on the stomach with the elbows bent and forearms flat on the ground. Elevate the trunk off the ground while tensing the abdominal muscles. Hold for 5 seconds, gradually building to longer holds.

Next, try a side plank. Lie on one side with the legs positioned one on top of the other. Rest on a bent elbow. Then engage the abs by tightening them and raise the trunk and hips off the ground. Hold for 5 seconds, building gradually to a hold of 30 seconds or longer.

Stomach vacuum

Stand up straight and take a deep breath into the stomach. Then exhale all the air from the lungs, drawing the stomach in. Envision the belly button moving toward the spine, sucking the stomach in as far as possible. Hold for 5-10 seconds, and repeat for several breaths. Once the stomach vacuum exercise is mastered, it is possible to perform while lying or sitting.

Lateral heel touches

Lateral heel touches target the obliques, which complement the appearance of an Adonis belt. Lie on the back with the knees bent and feet flat on the ground. Keep the arms extended out and parallel with the floor. While engaging the abdominal muscles, lift the head, neck, and upper back off the ground. Bend right to touch the right heel, then left to touch the left heel. Repeat for 5-10 repetitions.

Exercise ball crunches

Share on PinterestExercises that strengthen the muscles surrounding the inguinal ligament may give a more defined appearance.

Exercise ball crunches more effectively engage the abs than traditional crunches. Lie on an exercise ball such that the ball is positioned at the small of the back.

With the abs engaged and feet flat on the ground, perform a crunch by lifting the head, neck, and upper torso. The arms can be across the chest, behind the head, or extended straight, but should not be used to make it easier to crunch up. Repeat 5-10 times for 3-5 sets.

In a culture fixated on thinness, it is easy to see body fat as bad. Fat, however, plays a protective role. Everyone needs some fat to be healthy. Women are especially vulnerable to health problems when they shed too much body fat, because they have higher body fat percentages than men. Women with very low body fat may not menstruate, which can undermine or prevent fertility.

Women with body fat percentages below 15 percent are at risk of several health problems. This means that it may be difficult, and perhaps even impossible, for women to develop an Adonis belt and remain healthy. For men, health tends to decline when body fat dips below 8 percent, so most men can safely develop an Adonis belt.

13 ab toning exercises you can do from home (that work)

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  • Aka core strengthening moves you can do without switching off Netflix. What’s not to love?

    Ab toning exercises may sound super daunting, but if you’re looking to strengthen your core with some ab-focused moves, you’re in the right place. We’ve written a handy guide to the best core exercises you can do from the comfort of your home – with help from a qualified personal trainer, so you know the advice is legit.

    Note here: you don’t need to tone your abs. Mad sounding diets like the 4:3 diet, 5:2 diet, and Dukan diet are already circling social media. Don’t feel pressured, with summer coming up, to lose weight or change your body. You are enough as you are.

    But if you do want to build strength, or add a new set of workout moves to your repertoire, and can approach it from a positive mind space, these moves could help you build said strength, tone your abdominal muscles, and support your overall wellbeing.

    Don’t fret: if you can’t be bothered to venture outside, these ab toning moves are doable from your living room, bedroom, hallway, heck, even your kitchen. You need never search the internet for free home workouts and no kit sweat sessions again.

    Keep reading for pro advice from personal trainer, Pilates instructor and barre specialist Aimee Victoria Long.

    13 best ab toning exercises for beginners

    Long has approved the following moves – so know that they’re not just any old ab moves, but PT-approved ab toning exercises. As above, try the following once, twice or three times a week to complement your main workouts. It shouldn’t take any longer than ten minutes or so.

    Dead bugs

    Lie flat on your back with your arms extended towards the ceiling. Then lift your legs and bend your knees at 90° so your lower legs are parallel with the floor. Engage your core and draw your belly button in to get your back as flat against the floor as possible – you shouldn’t be able to get a hand in between your back and the floor, and you need to maintain this throughout. This means your core is engaged.

    Slowly lower your right arm behind your head and extend your left leg forwards at the same time, exhaling as you go. Keep going until your arm and leg are just above the floor, being careful not to raise your back off the floor (this is key) then, as you inhale, slowly return to the starting position and repeat with the opposite limbs.

    Plank shoulder taps

    In a high plank position with palms on floor, take your left hand off the floor and tap your right shoulder lower your left hand back to the floor and repeat on the other side. Making sure you aren’t letting your hips rock from side to side. Aim to perform for 30 seconds.

    Leg raises

    Lying on you back place your hands by the side of your bum. Stretch the legs out fully. Raise both legs off the floor and bring up to a 90 degree angle. Making sure that your spine remains in contact with the floor the whole time.

    To make exercise harder slow down the time it takes for you to lower your feet down to the floor

    Butterfly Crunches

    Lying on your back, place the soles of your feet together. Raise your legs high up off the bed to create a ‘butterfly’ shape. Crunch up towards your legs. Repeat 10 times.

    Slow Roll-Ups

    Lying flat on the bed, stretch your legs straight and your arms straight above your head. Very slowly, lift yourself up to a sitting position, reaching your arms down as if to touch your toes. Very slowly, as you count to five, lower yourself back down on the bed, back into a flat position. Repeat 10 times.

    Plank Lifts

    While in regular plank stance (aka holding your body in a straight line while balancing on the balls of your toes and elbows), lift your hips up high and bend your body to create an arch. Hold for two seconds and then lower your hips back down. Repeat 10 times.

    Quick ab toning exercises

    Vs

    Lying on your back, stretch your legs straight and your arms straight above your head. Slowly raise your legs and arms up, bending at the waist. Reach your hands toward your feet creating a ‘V’ shape with your body.  Repeat 10 times.

    Bicycles

    Lying on your back, bend your knees and place your hands behind your head, elbows bent. Raise your legs up into the air and one at a time, pull one knee forward while raising up to crunch the opposite elbow towards that knee. Continue ‘pedalling’, crunching the left elbow towards the right knee and the right elbow toward the left knee. Crunch 25 times on both sides.

    Pillow Prop

    Stack two pillows at the foot of your bed. Lie flat on the bed with your feet elevated and cross your arms over your chest. Breathe in deeply as you pull your stomach in towards your back. Breathe out as you lift your upper body towards your feet. Breathe in as you lie down again. Relax your muscles then repeat 5 times.

    X-Plank

    Similar to the regular plank, lying on your stomach, lift up on your elbows. Spread your legs wide and then lift up on your toes, holding body as straight as possible in this position.  Hold for at least 15 seconds and then release. Repeat three times.

    Roundhouse Kicks

    Lying on your back, place your hands down flat on the bed, palms down. Keeping your legs straight, lift your right leg off the bed and rotate it in the widest circle you possibly can; bringing your foot down, almost to where it touches the bed, then around to the side and back to center. While you are rotating your foot, keep your ab muscles tight in order to control the rotation of your foot in a slow and controlled manner. Circle your right leg 10 times then repeat on the other side.

    Side Planks

    While in regular plank stance, roll your hips to the side, propping yourself up on the side of your right foot. Hold your body straight, propped up on your right foot and right elbow for 15 seconds and then release. Switch to the left side and repeat.

    Ab toning exercises with weights

    Want an extra challenge? Grab a can of beans from the kitchen cupboard to use as a makeshift weight for this one:

    Russian twists

    Sitting on your back, pull yourself gently upwards so your feet and torso are raised. Then holding a weight with both hands, twist your torso to the right side so your arms are parallel with the floor, the move back into the centre and repeat on the left. Do this ten times.

    Good luck.

    V-Shaped Buttocks Exercises To Perk Up Your Peach

    V-Shaped Butt: How Can You Lift It?

    Each person’s body is unique, especially when it comes to its peachiest part – the buttocks. There are at least 4 widely recognized butt shapes, which are round, heart, square, and inverted V. The latter in particular is not that voluminous, which is a concern for many of its owners. They are eager to have a rounder and more defined shape or, in other words, turn the “V” upside down. This is why the v-shaped buttocks exercises mainly work the gluteus maximus (the largest muscle in the glute muscle group), which might help pump the butt up (5). So, if you are an owner of a V-shaped butt, read this article to learn about v-shaped buttocks exercises.

    Exercises For A Perkier V-Shaped Butt

    Deep Squats

    When it comes to growing your glutes, squat depth plays a paramount role. Squats are great v-shaped buttocks exercises. The deeper you squat, the more you flex your butt, making it work more than the quads. In a deep squat, you go lower than the 90-degree angle. However, squatting deep is not the hardest part of the exercise. The trick here is to return to your starting position. As a result, you need to be fit enough to perform this exercise, namely to have the high level of your muscle mobility and stability. So, here are how you squat your way to the ideal butt (11):

    1. Stand with your feet shoulder-width apart and flat on the ground.
    2. Brace your core and start pushing your hips back, shifting weight to your heels.
    3. Lower your hips, keeping your back perfectly straight.
    4. Go down as far as a couple inches beyond the ground.
    5. Reverse the movement, pressing into your heels and straightening your knees.
    6. Repeat.

    It is not necessary to go all the way down, especially if you are a beginner. What is more significant is maintaining the right form (11). If you squat really deep but with a hunchback, your glute muscles will not work to the fullest. Therefore, focus on doing the exercise correctly, even if you go below 90 degrees just for a few inches. No rush is needed here; eventually, you will get there.

    Read More: How Many Squats A Day Will Give You That Peach Booty Look?

    Benefits Of Deep/Full Squats

    Deep and full squats go with a number of advantages, and it will be difficult for you to ignore them. So, among the reasons why you should try deepening your squats are (1):

    • They engage a variety of muscles. During a deep squat, you contract your hamstrings, quads, and gastrocnemii, preserving your knee joint integrity.
    • They add to your flexibility. If you prefer parallel squats, there is a possibility that you might eventually become less flexible.
    • In a deep squat, the fulcrum is shifted to the quads and glutes, not the knees, as in the 90-degree squat.

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    Lunges

    Lunges are a compound exercise that engages a few muscles at a time. Not only does it set your glutes on fire, but it also burns your quadriceps, hamstrings, and calves. Moreover, lunges can improve your balance, adding to your body stability and equilibrium. Eventually, you will even notice an improvement in your gait (3). Therefore, by including this single exercise to your workout routine, you will achieve several goals.

    Lunges are valuable for those who want to get a perfect butt, since they target mainly the glutes – the biggest muscle group of your body. During the exercise, the gluteus maximus works particularly intensively, making your butt rounder. Accordingly, doing lunges regularly can help you get rid of the flatness on your bum (8).

    However, lunges are not that easy to perform due to the complexity of the form. Wrong angle and loss of balance are the common challenges faced by numerous people, especially those who are new to fitness. This is why it is highly advisable that beginners do lunges slowly and in front of the mirror. Here is how the form of the classic lunge should look (10):

    1. Keep your back straight and find stability. Tilt your core a little bit forward to enhance your balance.
    2. As you step forward with one leg, keep your knee at the 90-degree angle. Your foot must stand flat on the floor. Your task here is not to let the knee look inward, which you might be tempted to do. Do your best to keep your legs square.
    3. Press into the heel of your front leg to return to your starting position.
    4. Repeat.
    Variations Of Lunges For A V-Shaped Butt
    • Walking lunges. The name of this variation speaks for itself. Here you do traditional lunges but without standing at one point. After stepping your right leg forward, you do not reverse the move. Instead, you bring your left leg forward and then make another step with it (8).  
    • Reverse lunges. These are the same as the conventional lunges, with the only difference that here you make a step back (8). 
    • Lunges with equipment. Although lunges work your glutes pretty good without additional equipment, there are various ways you can maximize your muscle work. Here’s how:
      • Add weights. You can simply take two dumbbells into both of your hands to make your glutes work insanely hard. Adding weights will put even more pressure on your glutes, which will help you get the rounder butt. There is no need to be afraid of overloading your knees. In fact, the load will make your ankles work more, thus making them stronger. As for the knees, they do not suffer during lunges, unless you do not keep them at the 90-degree ankle. In addition, dumbbell lunges can strengthen your core and contribute to your body stability. With the weights, you are unlikely to sway from side to side. Similarly, dumbbell lunges can improve your form during squats, which are also very helpful for those with a V-shaped butt (4).
      • Use a step platform. To make your butt grow even faster, do lunges on a platform, which is quite an advanced version of the exercise. What you have to do is to step forward onto the platform. The form is the same as in the classic lunge. The higher the platform is, the greater is the impact. If you do not have a platform, you may substitute it with a bench or a chair, whatever you feel comfortable with (10).

    Read More: Squats vs Lunges: Which One of These Time-Honored Exercises is More Effective?

    Pointed Butt Raises On The Knees

    Being one of the classic v-shaped buttocks exercises, pointed butt raises are an integral part of any workout geared towards making a V-shaped butt rounder. The primary muscle that works during this exercise is glutes, but hamstrings and lower back are activated. Yet, it is considered a popular butt isolation exercise, since the main focus is still on the glute muscles. Unlike the previous exercises, this one is performed not in the standing position but on all fours. Therefore, you will need a mat in order not to hurt or graze your knees. To execute pointed butt raises correctly, do the following (9):

    1. Get down into your all-fours position on the mat. 
    2. Raise one leg up, holding the thigh parallel to the ground and pointing your toes up. Tighten your core in order not to arch your back. Put your hands shoulder-width apart for better balance.
    3. Raise the leg even higher, squeezing your glute muscles.
    4. Lower the leg to the starting position. Do not let your thigh go lower, keep it in line with your hip.
    5. Repeat.

    As for modifications, you might try adding weights to challenge your muscles. For example, you may put a dumbbell on the back knee of your working leg. Another option is to use ankle weights. If you are in the mood for a real challenge, do the raises in the plank position (9). Performing the exercise in the plank and concurrently adding weights is even more daring than any of the abovementioned variations.

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    Fire Hydrants

    Fire hydrant is another exercise that requires a mat. Like the pointed butt raises, fire hydrants engage all the glute muscles, hamstrings, and core. So get down on the floor and follow these steps (6):

    1. Take the all-fours position on your mat. Your hands must be shoulder-width apart, while the knees have to be directly under your hips.
    2. Keep your spine neutral and squeeze your core to allow better stability and equilibrium. Look at the mat, creating a straight line between your head and lumbar spine. 
    3. Lift your right leg out to the side, doing your best to keep the hip parallel to the ground. Do this without shifting your weight to the opposite side much, which might result in the form violation.
    4. Lower the leg to the starting position.
    5. Repeat.

    You are free to use ankle weights to make the exercise even harder and to change the V-shape of your buttocks. It is better to do fire hydrants after a set of multi-joint exercises, such as squats, push-ups, bench presses, etc. Since fire hydrants require much movement in the hip joint, they can hurt and restrict one’s movement. If you have such a problem, stop doing it immediately. Likewise, if you are doing this exercise with weights and consequently feel the pain, remove them (6).

    The Bottom Line

    First of all, it is not right to say that some butt type is better or worse than another. All butts are unique but look equally good. There is absolutely no reason to shame yourself or others for having a V-shape because there is nothing wrong with that. If they are satisfied with their forms, let them be and learn to love yourself as well. However, if you feel uncomfortable in your body and feel like it does not look the way you want it to, it is in your power to change it. 

    There are numerous ways in which you can transform your body without surgery. For instance, if you want to make your buttocks rounder and perkier, you can do deep squats, lunges, pointed butt raises on the knees, and fire hydrants. These are the best v-shaped buttocks exercises because they activate the gluteus maximus, which can add volume to your butt. Doing these regularly, you are likely to build your glute muscles and thus make your tush rounder.  

    FAQs

    What Else Should I Do Besides Physical Exercises To Grow My Glutes?

    You might want to analyze your eating habits, making sure that your diet is balanced. Your muscles will not grow, unless you consume enough carbohydrates, fats, and proteins. The latter are particularly significant for your musculoskeletal system. In fact, protein is responsible for the rebuilding of your muscles after an intense workout. Therefore, if you are dreaming about having sexy buttocks, this nutrient must be a vital element of your meal plan. Among the products rich in protein are milk, lean meat, fish, eggs, beans, and soy (2).

    What Do I Do If I Have A Flabby Butt?

    It is possible to lift your butt without resorting to a plastic surgery. All you need is an appropriate meal plan and perseverance to do the right exercises. You should do deadlifts and full squats with weights to get rid of the undesirable sagginess. However, apart from aiming to build the muscle, you should pay attention to your weight. You might need to shed some pounds before you can have beautiful buttocks, because your butt fat might be the reason for the sagginess. In connection, in case you make a decision to get rid of some fat, you should not hope to lose it only in the butt area. If you torch your fat, you torch it everywhere. In fact, cardio workouts cope with this task best of all (7).

    How Can V-Shaped Buttocks Exercises Turn Your Butt Into A Round One In A Week?

    To speak the truth, it is impossible to undergo such a drastic transformation in such a short term. Improving the shape of your buttocks requires a lot of time and determination. However, you will hardly notice any considerable changes in your buttocks in just a week, even if you choose to work out every day. In fact, working your glutes every day might do more harm than good, ultimately resulting in an injury. You need to let your muscles rest and recover. Hence, do not rush or give up. Eventually you will get what you want. Take up a challenge and try this 20-min Full Body Workout At Home to get a snatched body.

    DISCLAIMER:

    This article is intended for general informational purposes only and does not address individual circumstances. It is not a substitute for professional advice or help and should not be relied on to make decisions of any kind. A licensed physician should be consulted for diagnosis and treatment of any medical conditions. Any action you take upon the information presented in this article is strictly at your own risk and responsibility!

    SOURCES:

    1. 14 Reasons You Shouldn’t Ignore Full Squat Benefits! (2019, bodybuilding.com)
    2. 9 Things to Know About How the Body Uses Protein to Repair Muscle Tissue (2018, acefitness.org)
    3. Are All Lunges Created Equal? (2013, acefitness.org)
    4. Benefits of Dumbbell Lunges (n.d., livestrong.com)
    5. Best exercises depending on your butt shape (2016, smh.com.au)
    6. How to Do Fire Hydrant Butt Exercises (2008, sportsrec.com)
    7. How to Easily Lift a Sagging Butt (2019, livestrong.com)
    8. Lunges for a Rounder Butt (2019, livestrong.com)
    9. Pointed Butt Lift (n.d., exercise.com)
    10. Take The Lunge: Build Your Lower Body With This Overlooked Move! (2013, bodybuilding. com)
    11. The Optimal Squat Depth for Glute Gains, Explained (2020, livestrong.com)

    How to Build Eye-Popping V-Line Abs

    “Bro. I don’t care about getting stronger. That’s been easy for me. I just want to see my abs for the first time.”

    Sound familiar? It does to me.

    I regularly hear something like that from experienced lifters. They work hard and get strong. They have no interest in turning into bodybuilders. But they do have one aesthetic goal that’s often elusive:

    Building six-pack abs.

    And we’re not just talking about seeing the first two or four abs at the top. We’re talking about deep cut v-line abs with visible separation.

    What Are V-Line Abs?

    Unless you’re a skinny dude with the metabolism of a hummingbird on meth, deep-cut six-pack abs are visual proof of your discipline in the kitchen. They also say something about your training focus.

    Still, there are abs…and then there are v-line abs.

    V-line abs, when you’re lean enough to show your inguinal ligament, are called anything from “sex lines” to moneymakers. The V comes from the two ligaments that originate in your hips and extend to your pubic bone.

    Wannabe Abs vs Real Abs

    The V-lines are not a muscle and therefore cannot be directly trained.

    How can you make your abs pop?

    First, seriously commit to getting extremely lean. We’re talking in the neighborhood of 5-8% body fat or so. Yes, you read that right.

    Second, develop muscular abs. Though the actual “v-lines” are a ligament, it does help to have deep, muscular abs.  The more muscle you have, the more definition you’ll reveal once you reduce body fat.

    Get Lean First

    If I hear the phrase “abs are made in the kitchen” one more time, I might just gag on my protein shake.

    The problem is, the phrase is 100% true.

    Chances are you won’t be able to out-train a bad diet and get shredded enough to reveal v-line abs unless you’re blessed with great genetics. Alas, most of us aren’t.

    So you must diet my friend. Fat loss still comes down to energy balance. (Can I say: “double, alas?”)

    You must take in fewer calories than you burn each day to lose fat.

    The extreme leanness needed for v-line abs often requires a customized approach. Maintaining v-line abs is not possible all the time for most people. It’s more realistic to shoot for v-line abs only occasionally. My online training client, Naz, is an example. He built v-line abs for a recent photo shoot, then went back to something more sustainable.

    Ideally, I’d advise getting professional help. And guess what? I’m available. (A shameless plug, I know, but hey: I have a mortgage to pay and the doggie food bills are out of control.)

    But if you want to go it alone, the remainder of this blog post will explain how in five steps.   

    Beware:steps one and two may make your head spin. So unless you have an affinity for math, Consider skipping directly to Step 3.


    Step One: Determine Your Own Body Fat and Lean Body Mass

    Before determining a plan of action, you must determine where you currently are. Here is a visual display of body fat by percentage.

    BIA

    BIA, known bioelectrical impedance analysis, is a common body fat measurement tool. It often comes in the form of a handheld device or digital scale.

    BIA is notoriously sporadic and works by measuring electrical signals through your body. Hydration status and timing play a major role. These are highly variable, so you must be consistent with your timing of measurement as well as hydration. BIA analyzers are often quick and easy, but the numbers can be off by 5% or more.  

    Skinfold

    Skinfolds, when done with a skilled professional, can be as close as +/- 2-5%. These measure your levels of subcutaneous fat; the fat directly beneath your skin. These are a great option.

    DEXA is best

    Dexa scans, which normally cost anywhere from $25-$100, are the most accurate test and are generally spot on for measurements. If you want the best measurement possible, get a DEXA scan.

    Whatever option you choose to analyze body-fat, stay consistent. Different tools will likely yield different results.

    Step Two: Calculate How Much Fat You Need to Lose and How Long It Will Take

    Research has shown the maximum rate of fat loss to be about 1-2% of your body weight per week. There are times when you may lose more than this due to water weight and – ahem – bodily functions. But 1-2% is a good, consistent mark to shoot for.

    Let’s say you were 200 pounds at 16% body fat. First, we’ll calculate your lean body mass.

    200lbs x .84 (% of lean mass) = 168 pounds. You have 168 pounds of lean body mass (bone, water, muscle etc. ).

    If you need to be 5% bodyfat without losing any muscle, you would do this simple calculation.

    168 x1.05= 176 pounds.

    Therefore, your goal would be to diet to 176 pounds or so.

    Above, we talked about 1-2% being the maximum rate of fat loss. So at 200 pounds, at 16% body-fat, you can expect to lose 2-4 pounds per week at first; provided your diet and training are dialed in.  

    Fat loss will slow drastically the leaner you get. But for now, let’s “pretend” you maintain this amount of fat loss each week. You would need to calculate at the new bodyweight to be precise, but if you maintain 2-4 pounds of fat loss per week….

    … it would take you anywhere from 6-12 weeks of hard dieting to reach 5% body fat and have deep, v-cut abs.

    Step Three: Calculate Your Calories

    There are any number of equations to calculate the ideal number of calories to maximize fat loss. As with any fat loss diet, the goal is to minimize the loss of lean muscle and prevent your metabolism from adapting and slowing down.

    This means you need an aggressive, yet sane, diet. Research indicates a 20-25% caloric deficit is about as aggressive as you can go for moderate time periods without messing up your body.

    First, determine your maintenance calories. Then, we’ll find how many calories you need to create a deficit and carve away belly fat.

    For maintenance, we’ll use body weight (pounds) x 14.

    An active, 200-pound man (we’ll call him Gerard Butler) is 16% body fat and in shape but has no visible abs. He would need 200 lbs x 14 = 2,800 calories.

    To create a 20-25% deficit we’ll take…

    2,800 calories x.8= 2,240 calories per day.

    2,800 calories x.75= 2,100 calories per day.

    One caveat: If you’ve been dieting long-term, then this may be way off. Your metabolism can adapt to long periods of dieting, resulting in a metabolic slowdown. This stuff can get complicated when we’re talking’ about extreme leanness.

    Step Four: Nail Your Macros

    While calories are the most important component, the macronutrient split (how many grams of protein, fat, and carbohydrates) also counts. Some folks do better with higher carbs and low-fat, whereas others thrive with low-carb and high-fat diets. This is extremely variable from person to person.

    Protein

    During a fat loss diet eating a high-protein diet is essential to maintain lean muscle mass. This helps you maintain a sound metabolism and of course, helps you look “more jacked’ once you strip the fat off.

    At a minimum, I recommend 1g of protein per pound of bodyweight during fat loss phases, and often move this number as high as 1.2g/lb of bodyweight. Research shows 1g/lb to be the “maximum” benefit. If there’s one macronutrient you’re going to overconsume during an aggressive diet, best that it’s protein.

    Plus, protein is tasty! 

    Carbs

    As a general rule, 1g of carbs per pound of bodyweight is a safe bet. This is low enough. Unless you have significant fat to lose, or true blood sugar control problems, there is nothing wrong with a higher carbohydrate approach to lose fat. As long as your calories are low, higher carbs during a fat loss phase can lead to better workout performance and more balanced energy.

    Later in the diet, you can cut carbs in final prep mode. But again, this is an advanced strategy that requires customization in most cases.

    Fat

    The remainder of your calories will come from fat. You’ll need enough fat to maintain anabolic hormone levels, but not too many where you blow your calories out of the water.

    Here is how to break it down. We’ll run with

    • Calories: 2,100 per day.
    • Protein= 4 calories/gram  — 200 g protein (1g/lb) x 4= 800 calories
    • Carbs= 4 calories/gram =200 lbs (1g/lb) = 200g/carbs x 4= 800 calories

    2,100 calories -800 (from protein)  – 800 (from carbs) = 500 calories remain.

    • Fats= 9 calories/gram = 500 calories/9 calories/gram = 45 calories/gram.

    Altogether, a 200 pound Gerard Butler would aim for:

    • 2100 calories
    • 200 grams of carbs
    • 200 grams of protein
    • 45 grams of fat

    Track your calories with an app like MyFitnessPal. Yes, I know counting calories can be a pain in the ass, but I’ve never met anyone who’s gotten shredded without tracking his or her food.

    Track your diet, stick to your calories and macros, and reveal your abs once and for all.

    The Bottom Line

    Calories are king when it comes to fat loss, but macros are also important.  Take care of calories first, protein second, then test different amounts of carbohydrates versus fats. As long as your calories are on target, eat carbs and fats as it fits your preferred eating style.

    Step Five (Optional): Supplementation

    In most cases, I’m not a fan of supplements for fat loss. But once you’ve dialed in your diet and are training hard, a few supplements can accelerate fat loss. This is especially true for elite levels of leanness.

    Green Tea Extract

    The fat loss benefits of Green Tea are dose-dependent. According to Examine, the maximum fat loss benefits are achieved at high doses, such as 400-500 mg per day.

    Yohimbine

    Yohimbine can accelerate fat loss and aid in erectile dysfunction, but it’s not for everyone; particularly high-stress individuals and those with anxiety. Examine has found yohimbine to burn fat best on an empty stomach and be dose specific at /2 mg/kg body weight.

    This results in a dosage of:

    • 14 mg for a 150lb person
    • 18 mg for a 200lb person
    • 22 mg for a 250lb person

    Pre Workout: Coffee or Onnit T+

    When you’re dieting, hard training will occasionally be the last thing you’ll want to do. In this case, extra caffeine and/or pre-workout supplements will help.

    If you’re looking for additional fat burning, caffeine – and coffee in particular – is a useful tool.

    If you’d prefer to feel a pre-workout rush, without the “cracked” out feeling and often questionable products, then Onnit T+ is a winner. Since caffeine is a stimulant, over-reliance on it to maintain energy during a cut can lead to an increased cortisol response, which makes it easier to add body fat and lose muscle mass. This is obviously less than ideal, so consider going light on the caffeine if you need a pre-workout boost.

    All About Stress And Sleep

    Cortisol, the stress hormone,  can wreak havoc on your fat loss diet. Being that you’re already stressed and fat loss diets add an extra stressor, you must also manage stress to build your best-looking body.

    First, get more sleep. Your body needs rest, especially if you want to build muscle and stay lean. If you’re not getting six to eight hours of quality sleep per night, kiss your dreams of having sculpted abs goodbye.

    In one study published in Growth Hormone & IGF Research, researchers pointed to the fact men have one single burst of growth hormone released each day. And it happens during their sleep.

    Guys who sleep less and spend less time in slow-wave sleep tend to notice a decline in the amount of growth hormone released.

    Growth hormone is a powerful anti-aging hormone as well as a fat burner. Suboptimal levels of growth hormone can hinder fat loss.

    Sleep deprivation correlates with higher cortisol and lower testosterone levels.It hinders workout quality, decreases muscle building, and increases fat storage. Yikes.

    Second, start meditating. Meditation improves focus and productivity. It has a positive impact on nearly all areas of your health and decreases stress. Don’t be fooled by pictures of monks meditating in a peaceful garden; you don’t need to spend all day in a zen state. I recommend using the Headspace app and starting with 10 minutes per day at the same time every day.

    Adopting the simple habits of meditating and getting adequate sleep accelerates fat loss by improving hormone levels and reducing stress.

    Training For V-Line Abs

    Your workouts must include compound lifts like deadlifts, squats, pull-ups, and lunges as the foundation of your training.

    Lift three to four days per week and do some form of conditioning at least once or twice per week. Training for strength with big movements works your abs, stimulates the release of anabolic hormones like testosterone and growth hormone, and does more for building a beach-ready physique than any single ab routine.

    If you’re looking for a dedicated program to get you in tip-top shape without living in the gym, I’d recommend you check out this abs workout.

    Still, training your abs is vital to revealing chiseled abs and that coveted V-cut. Stronger and muscular abs create deeper separations and cuts between the rectus abdominis muscle, helping your abs remain visible even when your body fat is a bit higher.

    The Workout

    Perform this workout separate from your other weight training two times per week. If you need more than four weeks to get in tip-top shape (and you probably will) perform this routine twice a week for one month.

    Then, take one month completely off before returning for a second round as you wrap up your cut. This keeps the training stimulus novel; promoting gains. The planned break allows full recovery to maximize your hard work.

    1. Hollow Body Hold — 3x 45-60 seconds, rest 45-60 seconds

    A gymnastics move by nature, the hollow body hold teaches you to brace and hold neutral spine while contracting your entire rectus abdominis muscle.

    Lay flat on the ground, looking up. Flatten your lower back and flex your knees, pointing your toes away from you. Extend your legs in front of you while picking up your arms, keeping your back flat, and lifting your head and shoulders off the ground. Aim to do these twice a week.

    2. Ab Wheel – 3 x 6-10, rest 60-90 seconds

    Ab wheel rollouts are an absolute killer for ab development. Plus, they force you to resist the extension (arching) of your lower back while also training your lats, shoulders, and triceps.

    Kneel down, holding the handles of the wheel with your arms locked out beneath your shoulders. Brace your abs and roll out as far as possible, then roll back without shifting your hips or arching your lower back. Alternatively, the stability ball rollout is a great drill to progress towards the ab wheel.

    Start small: The ab wheel brings the pain and serious soreness. Start with two to three sets of six to eight reps twice per week. Add two reps per week (up to 15 or so), and then move on to adding a third set.

    3. Farmer’s Walk — 3 x 60 seconds, rest 60 seconds

    Dubbed the “most functional exercise” by experts like Gray Cook and Stuart McGill, farmer’s walks should be in every training program.

    Walking with heavy dumbbells in hand, your core is forced to dynamically stabilize the hip and midsection during every step, which fires up your abs and teaches deep stabilizing muscles to stay strong and hold position during other exercises.

    Grab a pair of heavy dumbbells and walk slowly — heel to toe — for 30 to 60 seconds, squeezing the dumbbells and staying as tall as possible throughout the entire set. Perform 3 sets of 30 to 60-second walks twice per week.

    4. Hanging Leg Raise 3×10-15, rest 60 seconds

    The hanging leg raise is a popular exercise for targeting the part of your abs below your belly button. By keeping your elbows slightly bent and shoulders retracted, you’ll also stretch the lats, build a stronger grip, and develop more muscular forearms.

    As with the other ab exercises in this list, keep your abs braced, and avoid arching your lower back. Grab a pull-up bar with a double overhand grip, squeezing the bar as tight as possible, and keeping the elbows slightly bent.

    Retract your shoulders, as if tucking them into your back pocket and holding them there.

    This protects the ligaments and tendons in your elbows and shoulders from unnecessary stress. From this position, flex your quads and bring your legs up just past 90 degrees, allowing your hips to roll up, forming an L shape with your body. Pause at the top for two seconds, then lower with control.

    Too Tough? Start by bending your knees and holding them up at 90 degrees for 5-10 seconds for each rep. Perform 3-4 sets of 10-15 reps twice per week

    Putting It All Together

    With a strategic plan of action, determination, and plenty of willpower, you can get the vaunted V-line abs that will make your physique stand out.

    But you must commit to eating right, training right, and recovering right.

    Here’s how:

    • Dedicate yourself to a diet that puts you in a caloric deficit.
    • Continue training with big, multi-joint lifts three to four times per week while doing a conditioning drill once or twice.
    • Refine your training and attack your abs twice per week with the exercises above.
    • Finally, sleep well and reduce stress. These are the secret weapons and the most commonly neglected aspects of transforming your body.

    With discipline, perseverance, and dedication, you’ll achieve the epitome of a lean beach-body: deep-cut abs and defined V lines.

    And if you’re looking for the perfect workouts and diets to get you there, start here: Bachperformance.com/coaching 

    Magnetic resonance imaging of the pituitary gland in healthy women of reproductive age | Dedov

    Magnetic resonance imaging (MPT) is the most informative method for diagnosing brain pathology. Its advantages are especially pronounced when assessing the state of the pituitary gland and parasellar structures. Due to its high resolution, the ability to obtain sections with a thickness of 2-3 mm in any plane, clear visualization of the anterior and posterior lobes of the pituitary gland, the pituitary funnel and adjacent structures such as the optic nerve intersection and cavernous sinuses, MRI is the method of choice in the diagnosis of hypothalamic-pituitary pathology. area.The first question that must be answered when evaluating the results of any MRI study is: “Is this MP-picture normal or corresponds to one or another pathological process?” Despite the highest diagnostic capabilities of the MRI method, the answer to this question sometimes presents great difficulties, since the size, shape, structure of the pituitary gland and its relationship with the surrounding structures are very diverse, therefore, the correct interpretation of the research results is often impossible without a thorough analysis of the patient’s clinical examination data. At the same time, in clinical practice, often any deviations in the structure of the pituitary gland from what is considered to be the norm are interpreted as a sign of the presence of a pathological process (most often microadenoma). Women of reproductive age are often referred for MRI to exclude pituitary pathology in various endocrine disorders. At the same time, the results of the MPT study, as the most informative method of radiation diagnostics, in some cases become the main argument for making a diagnosis and choosing a treatment method.The purpose of this study was to analyze the size, shape, structure and variants of the structure of the pituitary gland in healthy women of reproductive age, as well as to assess the diagnostic value and information content of magnetic resonance imaging in various projections. Materials and Methods The study included 294 women aged 21 to 40 years (mean age 29.79 ± 0.33 years). The selection criterion was the absence of clinical symptoms, laboratory data, and MPT signs indicating the presence of pathology of the hypothalamic-pituitary system, including the empty sella turcica syndrome. If a pituitary adenoma was suspected, contrast-enhanced studies and repeated studies were performed to exclude it. The study also did not include women during pregnancy and lactation. MPT studies were carried out in the MRI laboratory of the Endocrinological Research Center of the Russian Academy of Medical Sciences using a Siemens Magnetom Impact magnetic resonance tomograph with a magnetic field strength of 1 T. They included the following diagnostic sequences: 1) T1-SE (TA = 330 ms, TE = 12 ms, FA = 70 °), 3 mm sagittal slices, 256 x 256 matrix; 2) T1-SE (TA = 330 ms, TE = 12 ms, FA = 70 °), frontal sections 3 mm thick, matrix 256 x 256; 3) T2-TSE (TA = 5000 ms, TE = 199 ms, FA = 180 °), 3 mm sagittal slices, 256 x 256 matrix; 4) T2-TSE (TA = 5000 ms, TE = 119 ms, FA = 180 °), front sections 3 mm thick, matrix 256 x 256, sections 3 mm thick; 5) T2-TSE (TA = 5000 ms, TE = 119 ms, FA = 180 °), axial slices 3 mm thick, matrix 256 x 256, slices 3 mm thick.In this case, the following indicators were assessed in each case: the size of the pituitary gland in three projections; shape, symmetry of the pituitary gland; condition of the upper contour of the pituitary gland; the structure of the adeno- and neurohypophysis; the position of the pituitary funnel. Statistical analysis of the material was carried out using the computer programs Statistica (StatSoft, USA) and BIOSTAT (S. A. Glans; M .: Praktika, 1998). Data in the text and tables are presented as M + t, where M is the arithmetic mean; t is the standard error of the mean. Results and discussionThe analysis carried out in the work allowed us to draw conclusions about the diagnostic value of magnetic resonance imaging in various projections for assessing the structures of the hypothalamic-pituitary region (Table.one). At the same time, T1-weighted images made it possible to assess the structures of the adeno- and neurohypophysis, the state of the pituitary funnel (see figure, a, c), and T2-weighted images better revealed the contrast between soft tissue structures and CSF spaces, as well as the lateral borders of the sella turcica. cavernous sinuses (see figure, b, d). The size of the pituitary gland. Table 2 shows the results of measurements of the size of the pituitary gland in three planes for women aged 21 to 40 years. In addition, to calculate the approximate volume of the pituitary gland, we used the simplified formula for the volume of the ellipse Volume (in mm) = 0.5 • (sagittal dimension • transverse dimension ■ vertical dimension).We made an attempt to identify statistically significant changes in the size of the pituitary gland over the age period 21-40 Table 1 Diagnostic value of magnetic resonance imaging in various projections to assess the condition of the sella turcica, pituitary gland and extrasellar structures Projection Slice thickness, mm Diagnostic value Sagittal Frontal Axial MRI – the image of the pituitary gland and surrounding structures is normal. a – T1-weighted images, sagittal projection; b – T2-weighted images, sagittal projection; c – T1-weighted images, frontal projection; d – T2-weighted images, frontal projection./ – chiasm of the optic nerves; 2 – pituitary funnel; 3 – neurohypophysis; 4 – adenohypophysis; 5 – the sinus of the main bone. years. Comparison of different age groups did not give statistically significant differences in any of the studied quantitative indicators. The search for the correlation dependence using the rank correlation coefficient also did not reveal any regularities. Table 3 shows the average values ​​of the size of the pituitary gland for 4 age intervals of 5 years each. The shape and structure of the pituitary gland.In the majority of observations in the sagittal projection on the section, Table 2 Pituitary gland dimensions Indicator Minimum Maximum Average Vertical dimension, mm 3 9 5.8 ± 0.07 Transverse dimension, mm 9 19 13.9 ± 0.11 Sagittal dimension, mm 6 16 10.4 ± 0.08 Volume, mm3 136.5 728 418.9 ± 6.99 walking along the midline, the pituitary gland, as a rule, had an ellipsoidal shape; in the frontal plane, its shape was close to rectangular. In each case, we assessed the following indicators (Tables 4-7): the state of the upper contour of the pituitary gland, the structure of the adeno- and neurohypophysis, the symmetry of the pituitary gland, the position of the pituitary funnel, the structural features of the sella turcica and cavernous sinuses, the position of the neurohypophysis. Features of the structure of the sella turcica and cavernous sinuses, the position of the neurohypophysis. The shape of the lower contour of the pituitary gland repeats the shape of the bottom of the sella turcica, and in most cases, on the frontal sections, the lower contour of the sella turcica was located horizontally. In 7 (2.4%) cases, the bottom of the sella turcica was positioned obliquely, as a result of which there was an asymmetry in the location of the pituitary gland and the funnel. In 12 cases, on the border of the adeno- and neurohypophysis, there were small liquor-containing cavities – the remains of Rathke’s pocket.In 4 cases, an anomaly in the location of the syringe was noted. Table 3 Dimensions of the pituitary gland in different age groups = 63) Vertical dimension, mm Transverse dimension, mm Sagittal dimension, mm Volume, mm3 5.9 ± 0.13 13.9 ± 0.19 10.2 ± 0.14 421.3 ± 13.33 5.9 ± 0.13 13.6 ± 0.22 10.3 ± 0.14 415.3 ± 13.67 5.8 ± 0.14 14.2 ± 0.25 10.2 ± 0.18 414.1 ± 14. 68 5, 6 ± 0.14 13.9 ± 0.23 10.9 ± 0.21 425 ± 14.52 backgrounds of the internal carotid arteries: their loops protruded into the cavity of the sella turcica, narrowing it.The neurohypophysis was detected as a hyperintense area on T1-weighted images in the posterior part of the sella turcica. Sagittal slices are optimal for its visualization. In 238 (81%) cases, it was located in the midline, and in 56% (19%) it was displaced laterally. In some cases, difficulties arose in clearly distinguishing it from the hyperintense on T1-weighted images of the structures of the clivus; in these cases, the posterior border of the neurohypophysis is most clearly visible on T2-weighted images in the sagittal plane.The question of choosing a diagnostic sequence, tomography projections, slice thickness and other characteristics of MRI is extremely important, since the information content of the study largely depends on the correct answer to it. The main parameters of the study are set in advance and depend primarily on the object of visualization. Most of the authors [4, 6, 7] give the form of the upper contour of the pituitary gland in different age groups. The upper contour of the pituitary gland Age, years 21-25 (n = 89) 26-30 (n = 74) 31-35 (n = 68) 36-40 (n = 63) 21-40 (l = 294) Horizontal 80 (89.9) 67 (90.5) 58 (85.3) 54 (85.7) 259 (88.1) Concave 3 (3.4) 5 (6.8) 6 (8.8) 7 (11.1) 21 (7.1) Convex 6 (6.7) 2 (2.7) 4 (5.9) 2 (3.2) 14 (4.8) Note.Here and in table. 5-7 in brackets is a percentage. Table 5 Characteristics of the structure of the adenohypophysis Structure of the adenohypophysis Age, years 21-25 (l = 89) 26-30 (l = 74) 31-35 1 36-40 (l = 68) (l = 63) 21-40 (l = 294) Homogeneous 68 (76.4) 59 (79.8) 55 (80.0) 56 (88.9) 238 (80.9) Diffusely inhomogeneous 19 (21.4) 13 (17.6) S ( 14.7) 7 (11.1) 49 (16.7) Heterogeneous in the center 1 (1.1) 1 (1.3) 2 (2.9) 0 4 (1.4) Heterogeneous in the lateral regions 1 ( CD 1 (1.3) 1 (1.4) 0 3 (1.0) prefer anterior and sagittal T1-SE slices.According to our data, both T1 and T2 weighted images in all three projections are diagnostically valuable. However, often the study time is limited (for example, due to the psychological characteristics of the patient), as a result of which it is necessary to determine the most informative sequences. Our observations show that T1-weighted images in the frontal and sagittal projections, as well as T2-weighted images in axial and frontal projections, are absolutely necessary. In certain cases, T2-weighted sagittal images are also extremely important.Moreover, each of these sequences is aimed at obtaining information about the structure of certain structures (see Table 1). Dimensions in various projections are the most accessible quantitative indicator characterizing the state of the pituitary gland. According to our data, the sagittal, transverse and vertical dimensions of the pituitary gland were 10.4 ± 0.08, 13.9 ± 0.11, and 5.8 ± 0.07 mm, respectively. Sagittal and transverse dimensions in most cases are determined by the size of the sella turcica, while the vertical size is the most variable and most often changes with pituitary gland pathology. Most authors [6, 7] estimate the vertical size of the pituitary gland in pre-Table 6 Symmetry of the pituitary gland in different age groups Pituitary gland Age, years 21-25 (n = 89) 26-30 (n = 74) 31-35 (n = 68) 36-40 (u = 63) 21-40 (n = 294) Symmetrical 82 (92.1) 69 (93.2) 67 (98.5) 59 (93.7) 277 (94.2) Asymmetric 7 (7.9) 5 (6.8) 1 (1.5) 4 (6.3) 17 (5.8) Table 7 Position of the pituitary funnel in different age groups Position Age, years of the pituitary funnel 21-25 (l = 89) 26-30 (l = 74) 31-35 (l = 68) 36-40 (l = 63) 21-40 (l = 294) Along the midline 84 70 66 61 281 Rejected 5 4 2 2 13 ( 4.4) cases 3-8 mm.According to A. Elster [3], the maximum vertical size of the pituitary gland for women is 10 mm. In our study, the vertical dimension of the pituitary gland varied between 3 and 9 mm. In none of the 294 women, it did not reach 9 mm, which, in our opinion, allows us to consider this very size as the upper limit of the norm for this age group. At the same time, apparently, physiological hypertrophy of the adenohypophysis during puberty can lead to an increase in the vertical size of more than 9 mm. Analysis of the dependence of the size and volume of the pituitary gland on age in women aged 21-40 years did not reveal any regularities.This indicates that this age group is relatively homogeneous. In the frontal plane, the shape of the pituitary gland is usually close to rectangular, and in the sagittal projection on a cut passing along the midline, the pituitary gland, as a rule, has an ellipsoidal shape. Its structure is homogeneous in T1- and T2-weighted images. The pituitary funnel is located strictly in the midline. This description characterizes the MPT-picture of the normal pituitary gland [1]. Indeed, in our study, 72.8% of cases fit this description.At the same time, in 80 (27.2%) of 294 cases, there were some deviations from the “normal picture” of the MPT image of the pituitary gland. We analyzed the frequency with which such deviations occur. Most often, there was a heterogeneity of the structure of the adenohypophysis (19.1%). Moreover, in 16.7% of cases it was diffusely heterogeneous, in 1.4% – heterogeneous in the central part, and in 1.0% heterogeneity was noted on the periphery of the adenohypophysis. The lower contour of the pituitary gland follows the shape of the bottom of the sella turcica. The superior contour of the pituitary gland can be convex (4.8%), concave (7.1%), or horizontal (88.1%).It was noted that the incidence of the concave upper contour slightly increased with age (from 3.4% in women 21-25 years old to 11.1% in women 36-40 years old), which reflects a tendency towards flattening of the pituitary gland. A convex upper contour often raises suspicion of a pituitary adenoma. In puberty, the spherical shape of the pituitary gland is found in many healthy girls [2]. At the same time, it occurs in every twentieth healthy adult woman. The position of the pituitary funnel and the symmetry of the pituitary gland on the frontal and axial sections are one of the most obvious signs that make it possible to judge the presence of a particular pathology.Most often, the asymmetry of the pituitary gland and the deviation of the funnel are considered as signs of the presence of a pituitary microadenoma. In our study, the asymmetry of the pituitary gland to some extent was observed in 5.8% of women, and the deviation of the funnel from the midline – in 4.4%. This can be caused by a number of reasons, including the asymmetry of the Turkish saddle position, the inclined bottom of the Turkish saddle, asymmetric deformation of the lateral wall of the cavernous sinus due to an anomaly in the position of the siphon of the internal carotid artery. Thus, the listed and analyzed features of the MPT picture of the pituitary gland, which are often considered as indirect signs of the presence of a pituitary microadenoma [5], are often (27.2%) found in healthy women.We, of course, do not question the need for a thorough analysis of all the features of the image of the pituitary gland and its surrounding structures, however, a formal approach to the interpretation of the results of an MPT study can lead to serious diagnostic errors. In our opinion, the conclusion about the presence of a pituitary adenoma is valid only in those cases when its direct visualization is possible using all the possibilities of both non-contrast MRI and MRI with contrast enhancement. Conclusions 1.To obtain maximum information about the state of the pituitary gland and parasellar structures, it is optimal to conduct MRI in three projections, with a slice thickness of 3 mm, in the T1-SE and T2-SE modes. Any examination should include T1-weighted images in frontal and sagittal projections, as well as T2-weighted images in axial and frontal projections. 2. The size, shape and structure of the pituitary gland in healthy women of reproductive age are characterized by significant variability, which must be taken into account when interpreting MRI data.The maximum vertical dimension for women aged 21-40 does not exceed 9 mm. 3. In the group of healthy women aged 21-40 years, there is no statistically significant dependence of the size, shape and structure of the pituitary gland on age. 4. The so-called “indirect” signs of pituitary microadenoma are often found in various combinations and in healthy women; therefore, their detection cannot serve as the only basis for a diagnosis.

    90,000 The ONF created a “hot line” and a memo on the program to support domestic tourism

    The All-Russian Popular Front, with the support of the Roscongress Foundation and PJSC Rostelecom, launched a hotline for Russians, with the help of which they can get answers to their questions about the program to support domestic tourism.

    In addition, in order to inform about the conditions for obtaining a tourist cashback, ONF, together with the Association “Tourist Assistance”, prepared a special graphic memo with answers to common questions about the loyalty program. At the press conference “Russia in all its glory: start of the program to support domestic tourism” held in the Popular Front, experts spoke about the informational support of this campaign.

    “A lot of questions come to us from citizens that relate to the cashback program, how it will be possible to issue it, which regions it will be possible to go to, how to book a hotel or purchase a tour, whether the money will be returned soon.Therefore, the All-Russian Popular Front, together with the Association “Tourist Assistance”, with the support of the All-Russian campaign #WeAbout us, is opening a hotline on cashback issues at 8-800-200-3411. The call is free. Many are accustomed to planning their trips in advance, so before the official campaign stratum there is an opportunity to get acquainted with all the nuances, ”said ONF expert, Russian TV presenter and journalist Denis Polunchukov.

    “Hot line” #WeTogether has been operating since March 18, 2020 and today there is an opportunity to open a new direction of its work, continuing to use the technical capacities of the Fund, since the tourism industry is in a difficult situation.The government of the Russian Federation has formulated plans to support it and provide conditions for the dynamic development of domestic tourism. The task of the new direction of the “hot line” is to make it as easy as possible for tourists to get cash back. Our specialists have extensive experience working on hot lines, including in the framework of international, congresses, exhibitions, business, social, sports and cultural events. I am confident that a separate, tourist, area of ​​operation of the hotline will become a convenient “one-stop-shop” for all travelers in Russia, ”said Alexander Stuglev, Chairman of the Board, Director of the Roscongress Foundation.

    Director of the Association “Tourpomosch” Alexander Osaulenko said that “Tourpomosch” together with Rostourism has been conducting the same “hot line” for two weeks, but only for tour operators wishing to enter the program.

    Chairman of the All-Russian Association of Passengers Ilya Zotov called the key task of the ONF “hot line” “to explain and show the mechanism of the program so that every budget ruble is spent efficiently.” Zotov recommended that travelers buy tours, and not a separate hotel with transport, since airlines can cancel or reschedule flights, and buying tours in this situation will provide some safety.

    As a reminder, Russian Deputy Prime Minister Dmitry Chernyshenko said earlier that the tourist cashback program will start on the night of August 20-21 at 00:00 Moscow time and end at midnight on August 28.

    PHARMACOECONOMIC STUDY OF THE APPLICATION OF RIBOCYCLIB IN THE 1ST LINE OF THERAPY OF HER2-NEGATIVE HORMONE-DEPENDENT LOCALLY ADVANCED OR METASTATIC BREAST CANCER | Avksentiev

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    4. Clinical guidelines for the diagnosis and treatment of patients with breast cancer.Association of Oncologists of Russia, Moscow, 2014. Available at: http://oncology-association.ru/docs/ recomend / may2015 / 24vz-rek.pdf. [Clinical guidelines for the diagnosis and treatment of breast cancer. Russian Association of Oncologists, Moscow, 2014. Available at: http: // oncology-association. ru / docs / recomend / may2015 / 24vz-rek. pdf. (In Russ.)].

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    7. Plavinsky S.L., Shabalkin P.I. Use of an inhibitor of cyclin-dependent kinases 4/6 (palbociclib) in the treatment of hormone-dependent metastatic breast cancer. Cost-Impact Analysis. Siberian Journal of Oncology 2017; 4 (16): 19–25. [Plavinskiy S.L., Shabalkin P.I. Cyclindependent kinase 4/6 inhibitor (palbociclib) in the treatment of hormonedependent metastatic breast cancer. Cost – impact analysis.Sibirskiy onkologicheskiy zhurnal = Siberian Journal of Oncology 2017; 4 (16): 19–25. (In Russ.)].

    8. Hortobagyi G.N., Stemmer S.M., Burris H.A. et al. Ribociclib as first-line therapy for HR-positive, advanced breast cancer. N Engl J Med 2016; 375 (18): 1738-48. PMID: 27717303. DOI: 10.1056 / NEJMoa1609709.

    9. Sonke G.S., Hart L.L., Campone M. et al. Ribociclib with letrozole vs letrozole alone in elderly patients with hormone receptorpositive, HER2-negative breast cancer in the randomized MONALEESA-2 trial. Breast Cancer Res Treat 2018; 167 (3): 659-69. PMID: 2

    75. DOI: 10.1007 / s10549-017-4523-y.

    10. O’Shaughnessy J., Petrakova K., Sonke G.S. et al. Ribociclib plus letrozole versus letrozole alone in patients with de novo HR +, HER2-advanced breast cancer in the randomized MONALEESA-2 trial.Breast Cancer Res Treat 2018; 168 (1): 127-34. PMID: 29164421. DOI: 10.1007 / s10549-017-4518-8.

    11. Hortobagyi G.N. et al. Updated results from MONALEESA-2, a phase III trial of first-line ribociclib plus letrozole versus placebo plus letrozole in hormone receptor-positive, HER2-negative advanced breast cancer. Ann Oncol 2018 Apr 27. PMID: 29718092. DOI: 10.1093 / annonc / mdy155.

    12.Tremblay G., Chandiwana D., Dolph M. et al. Matching-adjusted indirect treatment comparison of ribociclib and palbociclib in HR +, HER2-advanced breast cancer. Cancer Manag Res 2018: 10: 1319-27. PMID: 29861642. DOI: 10.2147 / CMAR.S163478.

    13. Finn R.S., Crown J.P., Lang I. et al. The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole versus letrozole alone as first-line treatment of estrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-1 / TRIO-18): a randomized phase 2 study …Lancet Oncol 2015; 16 (1): 25–35. PMID: 25524798. DOI: 10.1016 / S1470-2045 (14) 71159-3.

    14. Finn R.S., Martin M., Rugo H.S. et al. Palbociclib and letrozole in advanced breast cancer. N Engl J Med 2016; 375 (20): 1925-36. DOI: 10.1056 / NEJMoa1607303.

    15. Data on the maximum size of wholesale mark-ups and the maximum size of retail mark-ups to prices for vital and essential medicines established in the constituent entities of the Russian Federation (data for the 4th quarter of 2017.) Available at: https://fas.gov.ru/documents/605937. [Information on the maximum wholesale and retail allowances for vital and essential medicines in the regions of the Russian Federation (as of Q4 2017). Available at: https://fas.gov.ru/documents/605937. (In Russ.)].

    16. Saad E.D., Katz A., Buyse M. Overall survival and post-progression survival in advanced breast cancer: a review of recent randomized clinical trials.J Clin Oncol 2010; 28 (11): 1958-62. PMID: 20194852. DOI: 10.1200 / JCO. 2009.25.5414.

    17. Decree of the Government of the Russian Federation of December 8, 2017 No. 1492 “On the Program of State Guarantees of Free Provision of Medical Care to Citizens for 2018 and for the Planning Period of 2019 and 2020”. [Decree of the Russian Federation Government No. 1492 dated December 8, 2017 “On the Program of state guarantees for free medical care for Russian citizens in 2018 and planning periods of 2019 and 2020”.(In Russ.)].

    18. Letter of the Ministry of Health of the Russian Federation No. 11-7 / 10 / 2-8080 dated November 21, 2017 “On methodological recommendations on methods of paying for medical care at the expense of compulsory medical insurance.” [Letter of the Ministry of Health of Russia No. 11-7 / 10 / 2-8080 dated November 21, 2017 “Methodical recommendations on options of paying for medical care using the funds of compulsory medical insurance”.(In Russ.)].

    19. Decree of the Government of the Russian Federation of 28.08.2014 No. 871 (as amended on 12.06.2017) “On approval of the Rules for the formation of lists of drugs for medical use and the minimum range of drugs required for the provision of medical care.” [Decree of the Russian Federation Government No. 871 dated August 28, 2014 (rev. As of June 12, 2017) “On the approval of Rules for forming the lists of medicines and the minimum assortment of medicines necessary for providing medical care”.(In Russ.)].

    Bulk-forming substances in the treatment of stress urinary incontinence in women | Tsukanov

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    3. Petros PE. The Female Pelvic Floor: Function, Dysfunction and Management According to the Integral Theory, 3rd ed. New York: Springer-Verlag; 2010. ISBN: 9783642037870.

    4.Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010; (1): CD005654 https://doi.org/10.1002/14651858. CD005654.pub2 Update in: Cochrane Database Syst Rev. 2014; 5: CD005654. PMID: 20091581.

    5. Abrams P, Cardozo L, Khoury S, Wein A. Incontinence: Proceedings from the 5th International Consultation on Incontinence.Plymouth UK: Health Publications; 2013. ISBN: 978- 9953-493-21-3

    6. Capobianco G, Madonia M, Morelli S, Dessole F, De Vita D, Cherchi PL, Dessole S. Management of female stress urinary incontinence: A care pathway and update. Maturitas. 2018; 109: 32‒38. https://doi.org/10.1016/j.maturitas.2017.12.008

    7. Kasyan G.R., Gvozdev M.Yu., Godunov B.N., Prokopovich M.A., Pushkar D.Yu. Analysis of the results of treatment of urinary incontinence in women using a free suburethral synthetic loop: experience of 1000 operations. Urology. 2013; (4): 5-11. eLIBRARY ID: 20589094

    8. Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev. 2017; 7 (7): CD006375.https://doi.org/10.1002/14651858.CD006375.pub4

    9. Pushkar DY, Godunov BN, Gvozdev M, Kasyan GR. Complications of mid-urethral slings for treatment of stress urinary incontinence. Int J Gynaecol Obstet. 2011; 113 (1): 54-57. https://doi.org/10.1016/j.ijgo.2010.10.024

    10. Wang C, Christie AL, Zimmern PE. Synthetic mid-urethral sling complications: Evolution of presenting symptoms over time.Neurourol Urodyn. 2018; 37 (6): 1937‒1942. https://doi.org/10.1002/nau.23534

    11. Kirchin V, Page T, Keegan PE, Atiemo KO, Cody JD, McClinton S, Aluko P. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev. 2017; 7 (7): CD003881. https://doi.org/10.1002/14651858. CD003881.pub4

    12.Chapple C, Dmochowski R. Particulate Versus Non-Particulate Bulking Agents In The Treatment Of Stress Urinary Incontinence. Res Rep Urol. 2019; 11: 299‒310. https://doi.org/10.2147/RRU.S220216

    13. Kocjancic E, Mourad S, Acar Ö. Complications of urethral bulking therapy for female stress urinary incontinence. Neurourol Urodyn. 2019; 38 Suppl 4: S12 ‒ S20. https://doi.org/10.1002/nau.23877

    14.Robinson D, Anders K, Cardozo L, Bidmead J, Dixon A, Balmforth J, Rufford J. What Do Women Want ?: Interpretation of the Concept of Cure. J Pelvic Med Surg. 2003; 9 (6): 273-277. https://doi.org/10.1097/01.spv.0000095060.05452.3f

    15. Murless BC. The injection treatment of stress incontinence. J Obstet Gynaecol Br Emp. 1938; 45: 67-73.

    16.ter Meulen PH, Berghmans LC, van Kerrebroeck PE. Systematic review: efficacy of silicone microimplants (Macroplastique) therapy for stress urinary incontinence in adult women. Eur Urol. 2003; 44 (5): 573-582. https://doi.org/10.1016/s0302-2838(03)00374-9

    17. Leone Roberti Maggiore U, Bogani G, Meschia M, Sorice P, Braga A, Salvatore S, Ghezzi F, Serati M. Urethral bulking agents versus other surgical procedures for the treatment of female stress urinary incontinence: a systematic review and meta -analysis.Eur J Obstet Gynecol Reprod Biol. 2015; 189: 48-54. https://doi.org/10.1016/j. ejogrb.2015.03.025

    18. Kiilholma PJ, Chancellor MB, Makinen J, Hirsch IH, Klemi PJ. Complications of Teflon injection for stress urinary incontinence. Neurourol Urodyn. 1993; 12 (2): 131-137. https://doi.org/10.1002/nau.1930120206

    19.Mamut A, Carlson KV. Periurethral bulking agents for female stress urinary incontinence in Canada. Can Urol Assoc J. 2017; 11 (6Suppl2): S152 ‒ S154. https://doi.org/10.5489/cuaj.4612

    20. Dmochowski RR, Appell RA. Injectable agents in the treatment of stress urinary incontinence in women: where are we now? Urology. 2000; 56 (6 Suppl 1): 32-40. https://doi.org/10.1016/s0090-4295(00)01019-0

    21.Lee PE, Kung RC, Drutz HP. Periurethral autologous fat injection as treatment for female stress urinary incontinence: a randomized double-blind controlled trial. J Urol. 2001; 165 (1): 153-158. https://doi.org/10.1097/00005392-200101000-00037

    22. Ghoniem G, Boctor N. Update on urethral bulking agents for female stress urinary incontinence due to intrinsic sphincter deficiency. J Urol Res. 2014; 1 (2): 1009.

    23. Cameron AP, Haraway AM. The treatment of female stress urinary incontinence: an evidenced-based review. Open Access J Urol. 2011; 3: 109‒120. https://doi.org/10.2147/OAJU. S10541

    24. Lai HH, Hurtado EA, Appell RA. Large urethral prolapse formation after calcium hydroxylapatite (Coaptite) injection. Int Urogynecol J Pelvic Floor Dysfunct.2008; 19 (9): 1315‒1317. https://doi.org/10.1007/s00192-008-0604-0

    25. Ghoniem GM, Miller CJ. A systematic review and metaanalysis of Macroplastique for treating female stress urinary incontinence. Int Urogynecol J. 2013; 24 (1): 27-36. https://doi.org/10.1007/s00192-012-1825-9

    26. Lose G, Mouritsen L, Nielsen JB.A new bulking agent (polyacrylamide hydrogel) for treating stress urinary incontinence in women. BJU Int. 2006; 98 (1): 100‒104. https://doi.org/10.1111/j.1464-410X.2006.06205.x

    27. de Vries AM, van Breda HMK, Fernandes JG, Venema PL, Heesakkers JPFA. Para-Urethral Injections with Urolastic® for Treatment of Female Stress Urinary Incontinence: Subjective Improvement and Safety. Urol Int. 2017; 99 (1): 91‒97.https://doi.org/10.1159/000452450

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    30. Sokol ER, Karram MM, Dmochowski R. Efficacy and safety of polyacrylamide hydrogel for the treatment of female stress incontinence: a randomized, prospective, multicenter North American study. J Urol. 2014; 192 (3): 843-849. https://doi.org/10.1016/j.juro.2014.03.109

    31. Kuhn A, Stadlmayr W, Lengsfeld D, Mueller MD.Where should bulking agents for female urodynamic stress incontinence be injected? Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19 (6): 817-821. https://doi.org/10.1007/s00192-007-0535-1

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    Heart attack

    Heart attack symptoms

    Common signs and symptoms of a heart attack include:

    • Chest pain or discomfort (angina) may present with a feeling of tightness, tightness, fullness, or pain in the center of the chest.With a heart attack, pain usually lasts for a few minutes and may increase and decrease in intensity.
    • Discomfort in the upper body, including arms, neck, back, jaw, or abdomen.
    • Difficulty breathing.
    • Nausea and vomiting.
    • Cold sweat.
    • Dizziness or fainting.
    • Women are less likely to have chest pain.

    Emergency treatment for heart attack

    The American Heart Association and the American College of Cardiology recommend:

    • If you think you are having a heart attack, call (03) right away.After calling (03), you need to chew an aspirin tablet. Be sure to inform the paramedic about this, then an additional dose of aspirin is not required.
    • Angioplasty, also called percutaneous coronary intervention (PCI), is a procedure that must be performed within 90 minutes of the onset of a heart attack. Patients suffering from a heart attack must be taken to a hospital equipped to perform PCI.
    • Fibrinolytic therapy should be given within 30 minutes of a heart attack if a center performing PCI is not available.The patient should be transferred to the PCI unit without delay.

    Secondary prevention of heart attack

    Additional preventive measures are needed to help prevent another heart attack. Before discharge, you need to discuss with the hospital doctor:

    • Control of blood pressure and cholesterol levels (statins, ACE inhibitors, beta-blockers are prescribed at discharge).
    • Aspirin and the antiplatelet drug clopidogrel (Plavix), which many patients must take on a regular basis.Prasugrel (Effient) is a new drug that can be used as an alternative to clopidogrel for patients.
    • Cardiac rehabilitation and regular exercise.
    • Normalization of weight.
    • Smoking cessation.

    Introduction

    The heart is a complex organ of the human body. Throughout life, it constantly pumps blood, supplying oxygen and vital nutrients to all body tissues through the arterial network.To accomplish this strenuous task, the heart muscle itself needs a sufficient amount of oxygenated blood, which is delivered to it through the network of coronary arteries. These arteries carry oxygen-rich blood to the muscular wall of the heart (myocardium).

    A heart attack (myocardial infarction) occurs when blood flow to the heart muscle is blocked, the tissue is deprived of oxygen and part of the myocardium dies.

    Ischemic heart disease is the cause of heart attacks.Coronary artery disease is the end result of atherosclerosis, which interferes with coronary blood flow and reduces the delivery of oxygenated blood to the heart.

    Heart attack

    Heart attack (myocardial infarction) is one of the most serious outcomes of atherosclerosis. It can happen for two reasons:

    • If a crack or rupture develops in an atherosclerotic plaque. Platelets are trapped in this area for sealing and a blood clot (thrombus) forms.A heart attack can occur if a blood clot completely blocks the passage of oxygen-rich blood to the heart.
    • If an artery becomes completely blocked due to a gradual increase in atherosclerotic plaque. A heart attack can occur if insufficient oxygen-rich blood passes through this area.

    Angina

    Angina, the main symptom of coronary artery disease, is usually perceived as chest pain.There are two types of angina pectoris:

    • stable angina pectoris. This is predictable chest pain that can usually be managed with lifestyle changes and certain medications, such as low doses of aspirin and nitrates.
    • unstable angina pectoris. This situation is much more serious than stable angina and is often an intermediate stage between stable angina and heart attack. Unstable angina is part of a condition called acute coronary syndrome.

    Acute coronary syndrome

    Acute coronary syndrome (ACS) is a severe and sudden heart condition that, with the necessary intensive treatment, does not turn into a full-blown heart attack. Acute coronary syndrome includes:

    • unstable angina. Unstable angina is a potentially serious condition in which chest pain is persistent but blood tests do not show markers of heart attack.
    • Non-ST-segment elevation myocardial infarction (not Q-myocardial infarction).Diagnosed when blood tests and ECGs reveal a heart attack that does not capture the full thickness of the heart muscle. The damage to the arteries is less severe than with a major heart attack.

    Patients diagnosed with acute coronary syndrome (ACS) may be at risk of heart attack. Doctors analyze the patient’s medical history, various tests, and the presence of certain factors that help predict which ACS patients are most at risk of developing a more serious condition.The severity of chest pain alone does not necessarily indicate the severity of the heart injury.

    Risk factors

    The risk factors for heart attack are the same as the risk factors for coronary heart disease. They include:

    Age

    The risk of coronary heart disease increases with age. About 85% of people who die from cardiovascular disease are over 65 years of age. In men, on average, the first heart attack develops at the age of 66.

    Floor

    Men are at a greater risk of developing coronary artery disease and heart attacks at an earlier age than women.The risk of cardiovascular disease in women increases after menopause, and they begin to suffer from angina more than men.

    Genetic factors and family inheritance

    Several genetic factors increase the likelihood of developing risk factors such as diabetes, high cholesterol, and high blood pressure.

    Racial and ethnicity

    African Americans have the highest risk of cardiovascular disease due to their high incidence of high blood pressure, diabetes and obesity.

    Medical background

    Obesity and metabolic syndrome. Excessive fat storage, especially around the waist, can increase the risk of heart disease. Obesity also contributes to the development of high blood pressure, diabetes, which affect the development of heart disease. Obesity is especially dangerous when it is part of metabolic syndrome, a pre-diabetic condition associated with heart disease. This syndrome is diagnosed when three of the following conditions are present:

    • Abdominal obesity.
    • Low HDL cholesterol.
    • High triglyceride levels.
    • High blood pressure.
    • Insulin resistance (diabetes or prediabetes).

    Elevated cholesterol levels. Low-density lipoprotein (LDL) is the “bad” cholesterol responsible for many heart problems. Triglycerides are another type of lipids (fatty molecules) that can be harmful to the heart. High-density lipoprotein cholesterol (HDL) is the “good” cholesterol that helps protect against heart disease.Doctors analyze a “total cholesterol” profile that includes measurements of LDL, HDL, and triglycerides. The ratios of these lipids can affect the risk of developing cardiovascular disease.

    High blood pressure. High blood pressure (hypertension) is associated with the development of coronary artery disease and heart attack. Normal blood pressure figures are below 120/80 mm Hg. High blood pressure is generally considered to be blood pressure greater than or equal to 140 mmHg. (systolic) or greater than or equal to 90 mm Hg.Art. (diastolic). Prehypertension is blood pressure with numbers 120 – 139 systolic or 80 – 89 diastolic, it indicates an increased risk of developing hypertension.

    Diabetes. Diabetes, especially for people whose blood sugar is not well controlled, significantly increases the risk of developing cardiovascular disease. In fact, heart disease and strokes are the leading causes of death in people with diabetes. People with diabetes also have a high risk of developing hypertension and hypercholesterolemia, bleeding disorders, kidney disease, and nerve dysfunctions, all of which can lead to heart damage.

    Lifestyle factors

    Reduced physical activity. Exercise has a number of effects that benefit the heart and circulation, including cholesterol and blood pressure levels and weight maintenance. People who are sedentary are almost twice as likely to have heart attacks as people who exercise regularly.

    Smoking. Smoking is the most important risk factor for cardiovascular disease.Smoking can raise blood pressure, disrupt lipid metabolism, and make platelets very sticky, increasing the risk of blood clots. Although heavy smokers are at the greatest risk, people who smoke as little as three cigarettes a day have a high risk of blood vessel damage, which can lead to impaired blood supply to the heart. Regular exposure to secondhand smoke also increases the risk of heart disease in nonsmokers.

    Alcohol. Drinking alcohol in moderation (one glass of dry red wine a day) can help raise your “good” cholesterol (HDL) levels.Alcohol can also prevent blood clots and inflammation. In contrast, drunkenness harms the heart. In fact, cardiovascular disease is the leading cause of death for alcoholics.

    Diet. Diet can play an important role in protecting the heart, especially by reducing dietary sources of trans fat, saturated fat, and cholesterol, and limiting salt intake, which contributes to high blood pressure.

    NSAIDs and COX-2 inhibitors

    All non-steroidal anti-inflammatory drugs (NSAIDs), with the exception of aspirin, are a risk factor for the heart.NSAIDs and COX-2 inhibitors may increase the risk of death in patients who have had a heart attack. The risk is greatest at higher doses.

    NSAIDs include over-the-counter drugs such as ibuprofen (Advil, Motril) and prescription drugs such as diclofenac (Cataflam, voltaren). Celecoxib (Celebrex), a COX-2 inhibitor that is available in the United States, has been associated with cardiovascular risks such as heart attack and stroke. Patients who have had heart attacks should consult their doctor before taking any of these medications.

    The American Heart Association recommends that patients who have or are at risk of heart disease primarily use non-drug methods of pain relief (eg, physical therapy, exercise, weight loss to reduce stress on joints, and heat or cold therapy). If these methods do not work, patients should take low doses of acetaminophen (Tylenol) or aspirin before using NSAIDs, and the COX-2 inhibitor celecoxib (Celebrex) should be used last.

    Forecast

    Heart attacks can be fatal, become chronic, or lead to complete recovery. The long-term prognosis for life expectancy and quality of life after a heart attack depends on its severity, the damage to the heart muscle, and the preventive measures taken thereafter.

    Patients who have had a heart attack have a higher risk of having another heart attack. Although there are no tests that can predict whether another heart attack will occur, patients themselves can avoid another heart attack by following a healthy lifestyle and adhering to treatment.Two thirds of patients who have had a heart attack do not take the necessary steps to prevent it.

    A heart attack also increases the risk of other heart problems, including abnormal heart rhythms, heart valve damage, and stroke.

    Persons at greatest risk. A heart attack is always more serious in some people, such as:

    • Elderly.
    • People with heart disease or multiple risk factors for cardiovascular disease.
    • People with heart failure.
    • People with diabetes.
    • People on continuous dialysis.
    • Women are more likely to die of a heart attack than men. The risk of death is highest in young women.

    Factors that occur during a heart attack that increase the severity.

    The presence of these conditions during a heart attack can contribute to a worsening prognosis:

    • Arrhythmias (heart rhythm disturbances).Ventricular fibrillation is a dangerous arrhythmia and one of the leading causes of early death from heart attack. Arrhythmias are more likely to occur within the first 4 hours of a heart attack and are associated with high mortality. However, patients who are successfully treated have the same long-term prognosis as patients without arrhythmias.
    • Cardiogenic shock. This very dangerous situation is associated with very low blood pressure, decreased urinary output, and metabolic disturbances. Shock occurs in 7% of heart attacks.
    • Heart block, also called atrioventricular (AV) block, is a condition in which the electrical conduction of nerve impulses to the muscles in the heart is slowed down or interrupted. Although heart block is dangerous, it can be effectively treated with a pacemaker and rarely causes any long-term complications in surviving patients.
    • Heart failure. The damaged heart muscle is unable to pump the blood necessary for the tissues to function.Patients experience fatigue, shortness of breath, and fluid retention in the body.

    Symptoms

    Heart attack symptoms vary. They may come on suddenly and be severe, or they may progress slowly, starting with mild pain. Symptoms can differ between men and women. Women are less likely than men to have classic chest pain, they are more likely to experience shortness of breath, nausea or vomiting, back pain and jaw pain.

    Common signs and symptoms of heart attack include:

    • Chest pain.Chest pain or discomfort (sore throat) is the main symptom of a heart attack and can be felt as a feeling of tightness, tightness, fullness, or pain in the center of the chest. Patients with coronary artery disease who have stable angina often experience chest pain that lasts a few minutes and then goes away. With a heart attack, pain usually lasts more than a few minutes and may go away but then return.
    • Upper body discomfort. People who are experiencing a heart attack may feel discomfort in their arms, neck, back, jaw, or stomach.
    • Difficulty breathing may be accompanied by chest pain or no pain.
    • Nausea and vomiting.
    • Cold sweat.
    • Dizziness or fainting.

    The following symptoms are less common with a heart attack:

    • Sharp pain when breathing or coughing.
    • Pain that is mainly or only in the middle or lower abdomen.
    • Pain that may be caused by touch.
    • Pain that may be caused by movement or pressing on the chest wall or arm.
    • Pain that is constant and lasts for several hours (do not wait several hours if a heart attack is suspected).
    • Pain that is very short and lasts for a few seconds.
    • Pain that spreads to the legs.
    • However, these signs do not always rule out serious heart disease.

    Painless ischemia

    Some people with severe coronary artery disease may not have angina. This condition is known as painless ischemia. It is a dangerous condition because patients do not have alarming symptoms of heart disease. Some studies show that people with painless ischemia have a greater risk of complications and mortality than those with angina pain.

    What to do with a heart attack

    People who are experiencing symptoms of a heart attack should follow these steps:

    • For angina patients, take one dose of nitroglycerin (sublingual or aerosolized tablet) when symptoms appear.Then another dose every 5 minutes, up to three doses, or until pain decreases.
    • Call (03) or dial the local emergency number. This should be done first if three doses of nitroglycerin do not relieve chest pain. Only 20% of heart attacks occur in patients with previously diagnosed angina. Therefore, anyone who develops symptoms of a heart attack should contact emergency services.
    • The patient should chew aspirin (250-500 mg), which should be reported to the arriving emergency service, as an additional dose of aspirin in this case does not need to be taken.
    • A patient with chest pain should be transported immediately to the nearest emergency room, preferably by ambulance. Traveling on your own is not recommended.

    Diagnostics

    When a patient with chest pain is admitted to the hospital, the following diagnostic steps are taken to identify heart problems and, if present, their severity:

    • The patient should inform the doctor about any symptoms that may indicate heart problems or possibly other serious medical conditions.
    • An electrocardiogram (ECG) is a record of the electrical activity of the heart. It is a key tool for determining if chest pains are related to heart problems and, if so, how severe they are.
    • Blood tests show an increase in the levels of certain factors (troponins and CPK-MB) that indicate heart damage (the doctor will not wait for results before starting treatment, especially if he suspects a heart attack).
    • Imaging techniques, including echocardiography and perfusion scintigraphy, can help rule out a heart attack if you have any questions.

    Electrocardiogram (ECG)

    An electrocardiogram (ECG) measures and records the electrical activity of the heart, the ECG waves correspond to the contraction and relaxation of certain structures in different parts of the heart. Certain waves on the ECG are named with the corresponding letters:

    • R. P-waves are associated with atrial contractions (two chambers in the heart that receive blood from the organs).
    • QRS. The complex is associated with ventricular contractions (the ventricles are the two main pumping chambers in the heart.)
    • T and U. These waves accompany ventricular contractions.

    Doctors often use terms such as PQ or PR interval. This is the time it takes for an electrical impulse to travel from the atria to the ventricles.

    The most important in the diagnosis and treatment of a heart attack are the ST segment elevation and the definition of the Q wave.

    ST segment elevation: Heart attack. Elevation of the ST segment is an indicator of a heart attack. It indicates that the artery of the heart is blocked and the heart muscle is damaged to its full thickness.Q-myocardial infarction (myocardial infarction with ST-segment elevation) develops.

    However, ST elevation does not always mean that the patient is having a heart attack. Inflammation of the bursa (pericarditis) is another cause of ST segment elevation.

    Without ST segment elevation: angina pectoris and acute coronary syndrome.

    A depressed or horizontal ST segment suggests conduction abnormalities and cardiovascular disease, even if there is no angina at present.ST segment changes occur in about half of patients with various heart diseases. However, in women, ST segment changes can occur without heart problems. In such cases, laboratory tests are needed to determine the extent of damage to the heart, if any. Thus, one of the following conditions may develop:

    • Stable angina (blood test or other test results do not show any major problems and chest pain disappears).During this period, in 25 – 50% of people with angina pectoris or painless ischemia, normal ECG values ​​are recorded.
    • Acute coronary syndrome (ACS). It requires intensive treatment until it turns into a massive heart attack. ACS includes either unstable angina or myocardial infarction without ST-segment elevation (not Q-myocardial infarction). Unstable angina is a potentially serious event with persistent chest pain, but blood tests do not reveal markers of heart attack.In non-Q myocardial infarction, blood tests detect a heart attack, but the damage to the heart is less severe than in a full-blown heart attack.

    Echocardiogram (ECHOKG)

    An echocardiogram is a non-invasive technique that uses ultrasound to visualize the heart. It is possible to determine the damage and mobility of areas of the heart muscle. Echocardiography can also be used as an exercise test to detect the location and extent of damage to the heart muscle during illness or shortly after hospital discharge.

    Radionucleide methods (stress test with thallium)

    They allow visualizing the accumulation of radioactive tracers in the heart area. They are usually given intravenously. This method allows you to evaluate:

    • Severity of unstable angina when less expensive diagnostic methods are not effective.
    • Severity of chronic coronary heart disease.
    • Success of surgery for coronary heart disease.
    • A heart attack has occurred.
    • Location and extent of heart muscle damage during illness or shortly after discharge from hospital after suffering a heart attack.

    The procedure is non-invasive. It is a reliable method for a variety of severe heart conditions and can help determine if damage is due to a heart attack. The radioactive isotope thallium (or technetium) is injected into the patient’s vein. It binds to red blood cells and travels with the blood through the heart.The isotope can be traced to the heart using special cameras or scanners. Images can be synchronized with ECG. The test is performed at rest and during exercise. If damage is detected, the image is retained for 3 or 4 hours. Damage caused by a heart attack will persist when re-scanned, and damage caused by angina pectoris will be leveled.

    Angiography

    Angiography is invasive. It is used for patients with angina pectoris confirmed by stress tests or other methods and for patients with acute coronary syndrome.Procedure progress:

    • A narrow tube (catheter) is inserted into an artery, usually an arm or leg, and then passed through the vessels to the coronary arteries.
    • A contrast agent is injected through a catheter into the coronary arteries and a recording is made.
    • This results in images of the coronary arteries showing obstructions to blood flow.

    Biological markers

    When heart cells are damaged, they release various enzymes and other substances into the bloodstream.Elevated levels of these markers of heart damage in the blood or urine can help identify a heart attack in patients with severe chest pain and help guide treatment. Tests like these are often done in the emergency room or hospital if a heart attack is suspected. Most commonly identified markers:

    • troponins. Cardiac troponin T and I proteins are released when the heart muscle is damaged. These are the best diagnostic signs of heart attacks.They can help diagnose and confirm the diagnosis in patients with ACS.
    • myocardial creatine kinase (CPK-MB). CPK-MB is a standard marker, but its sensitivity is less than that of troponin. Elevated levels of CPK-MB can be observed in people without heart disease.

    Treatment

    Treatments for heart attack and acute coronary syndrome include:

    • Oxygen therapy.
    • Relief of pain and discomfort with nitroglycerin or morphine.
    • Correction of arrhythmia (abnormal heart rhythm).
    • Block further blood clotting (if possible) with aspirin or clopidogrel (Plavix) and anticoagulants such as heparin.
    • Opening of the artery in which the cow flow has been disturbed should be opened as soon as possible by performing angioplasty or with the help of drugs that dissolve the blood clot.
    • Beta blockers, calcium channel blockers, or angiotensin-converting enzyme inhibitors are prescribed to improve heart muscle and coronary artery function.

    Immediate actions

    The same for patients with both ACS and heart attack.

    Oxygen. It is usually given through a tube into the nose or through a mask.

    Aspirin. The patient is given aspirin if it has not been taken at home.

    Medicines for relieving symptoms:

    • Nitroglycerin. Most patients will receive nitroglycerin both during and after a heart attack, usually under the tongue. Nitroglycerin lowers blood pressure and dilates blood vessels, increasing blood flow to the heart muscle.Nitroglycerin is sometimes given intravenously (recurrent angina, heart failure, or high blood pressure).
    • Morphine. Morphine not only relieves pain and reduces anxiety, but also dilates blood vessels, increasing the flow of blood and oxygen to the heart. Morphine can lower blood pressure and make it easier for the heart. Other drugs can be used as well.

    Removal of obstruction of coronary vascular flow: emergency angioplasty or thrombolytic therapy

    In a heart attack, clots form in the coronary arteries that obstruct coronary flow.Removal of clots in the arteries should be done as soon as possible, this is the best approach to improve survival and reduce the amount of damage to the heart muscle. Patients should be admitted to specialized medical centers as quickly as possible.

    Standard medical and surgical procedures include:

    • Angioplasty, also called percutaneous coronary intervention (PCI), is the preferred procedure for emergency opening of arteries.Angioplasty should be performed promptly for patients with a heart attack, preferably within 90 minutes of arriving at the hospital. In most cases, a stent is placed in the coronary artery, which creates an internal scaffold and improves the patency of the coronary artery.
    • Thrombolytics dissolve the clot and are the standard drugs used to open arteries. Thrombolytic therapy should be given within 3 hours of symptom onset. Patients who are admitted to a hospital unable to perform PCI should receive thrombolytic therapy and be transferred to a PCI center without delay.
    • Coronary artery bypass grafting (CABG) is sometimes used as an alternative to PCI.

    Thrombolytics

    Thrombolytic or fibrinolytic drugs are recommended as an alternative to angioplasty. These drugs dissolve the clot, or blood clot, that is responsible for blocking an artery and causing cardiovascular death.

    Generally speaking, thrombolysis is considered a good choice for patients with myocardial infarction in the first 3 hours. Ideally, these medications should be given within 30 minutes of arriving at the hospital unless angioplasty is being performed.Other situations where thrombolytics are used:

    • The need for long-term transportation.
    • Long period of time before PCI.
    • Failure of PCI.

    Thrombolytics should be avoided or used with great caution in the following patients after a heart attack:

    • In patients over 75 years of age.
    • If symptoms persist for more than 12 hours.
    • Pregnant women.
    • People who have recently suffered an injury (especially a head injury) or surgery.
    • People with exacerbation of peptic ulcer disease.
    • Patients who have undergone long-term cardiopulmonary resuscitation.
    • When taking anticoagulants.
    • Patients who have suffered a major loss of cows.
    • Stroke patients.
    • Patients with uncontrolled high blood pressure, especially when the systolic pressure is above 180 mm.Hg

    Standard thrombolytic drugs are recombinant tissue plasminogen activators (TAP): Alteplase (Actelize) and Reteplase (Retalize), as well as a new agent tenecteplase (Metalize). A combination of antiplatelet and anticoagulant therapy is also used to prevent clot enlargement and the formation of a new one.

    Rules for the administration of thrombolytics. The sooner thrombolytics are given after a heart attack, the better. Thrombolytics are most effective during the first 3 hours.They can still help up to 12 hours after a heart attack.

    Complications. Hemorrhagic stroke usually occurs on the first day and is the most serious complication of thrombolytic therapy, but fortunately this rarely occurs.

    Revascularization procedures: angioplasty and bypass surgery

    Percutaneous coronary intervention (PCI), also called angioplasty, and coronary artery bypass grafting are standard surgeries to improve coronary blood flow.These are known as revascularization surgeries.

    • Emergency angioplasty / PCI is a standard procedure for heart attacks and must be performed within 90 minutes of its onset. Studies have shown that balloon angioplasty and stenting are not able to prevent heart complications in patients when they are performed 3 to 28 days after a heart attack.
    • Coronary artery bypass grafting is usually used as elective surgery, but can sometimes be done after a heart attack, if angioplasty or thrombolytic therapy has failed.It is usually performed over several days to allow the heart muscle to heal.
      Most patients are suitable for thrombolytic therapy or angioplasty (although not all centers are equipped for PCI).

    Angioplasty / PCI includes the following steps:

    • A narrow catheter (tube) is inserted into the coronary artery.
    • The vessel lumen is restored when a small balloon is inflated (balloon angioplasty).
    • After deflation of the balloon, the vessel lumen increases.
    • A device called a coronary stent, an expandable metal mesh tube that is implanted into an artery during angioplasty, is used to keep an artery open for a long time. The stent can consist of bare metal, or it can be coated with a special drug that is slowly released into the adjacent wall of the vessel.
    • The stent restores the vessel lumen.

    Complications occur in about 10% of patients (about 80% of them during the first day). Best results are achieved in hospitals with experienced staff. Women who undergo angioplasty after a heart attack have a higher risk of death than men.
    Restenosis after angioplasty. Narrowing after angioplasty (restenosis) can occur within a year after surgery and requires a repeat of the PCI procedure.

    Drug eluting stents coated with sirolimus or paclitaxel may help prevent restenosis.They may be better than a bare metal stent for patients who have had a heart attack, but they can also increase the risk of blood clots.

    It is very important for patients with drug eluting stents to take aspirin and clopidogrel (Plavix) for at least 1 year after stenting to reduce the risk of blood clots. Clopidogrel, like aspirin, helps prevent platelets from sticking together. If, for some reason, patients are unable to take clopidogrel along with aspirin after angioplasty and stenting, bare metal stents should be implanted without drug coverage.Prasugrel is a newer alternative to clopidogrel.

    Coronary bypass surgery (CABG). It is an alternative to angioplasty in patients with severe angina pectoris, especially those with two or more occluded arteries. This is a very aggressive procedure:

    • The chest opens and blood is pumped using a heart-lung machine.
    • During the main phase of the operation, the heart stops.
    • Bypassing the closed sections of the arteries, shunts are sutured, which are taken during the operation from the patient’s leg, or from the arm and chest. Thus, blood flows to the heart muscle through shunts bypassing the closed sections of the arteries.

    Mortality in CABG after a heart attack is significantly higher (6%) than when the operation is performed as planned (1-2%). How and when it should be used after a heart attack remains controversial.

    Treatment of patients with shock or heart failure

    Seriously ill patients with heart failure or who are in a state of cardiogenic shock (it includes a decrease in blood pressure and other disorders) are intensively treated and monitored: they give oxygen, inject fluids, regulate blood pressure, dopamine, dobutamine and other drugs are used.

    Heart failure. Furosemide is administered intravenously. Patients may also be given nitrates and ACE inhibitors if there is no sharp drop in blood pressure when indicated. Thrombolytic therapy or angioplasty may be done.

    Cardiogenic shock. The intra-aortic balloon counterpulsation (IABP) procedure can help patients with cardiogenic shock when used in combination with thrombolytic therapy. A balloon catheter is used that inflates and descends into the aorta during certain phases of the cardiac cycle, thus increasing blood pressure.Also, an angioplasty procedure can be performed.

    Treatment of arrhythmias

    Arrhythmia is a heart rhythm disorder that can occur when oxygen is deficient and is a dangerous complication of a heart attack. A fast or slow heart rate is common in people with a heart attack and is usually not a dangerous sign.

    Extrasystole or a very fast rhythm (tachycardia) can lead to ventricular fibrillation. This is a life-threatening arrhythmia in which the ventricles of the heart contract very quickly, not providing sufficient cardiac output.The pumping action of the heart, necessary to maintain blood circulation, is lost.

    Prevention of ventricular fibrillation. People who develop ventricular fibrillation are not always exposed to arrhythmia prevention, and there are currently no effective drugs to prevent arrhythmias during a heart attack.

    • Potassium and magnesium levels must be monitored and maintained.
    • The use of intravenous and oral beta blockers may help prevent arrhythmias in some patients.

    Treatment for ventricular fibrillation:

    • Defibrillators. Patients who develop ventricular arrhythmias are given an electrical shock with a defibrillator to restore normal rhythm. Some studies show that implantable cardioverter-defibrillators (ICDs) can prevent further arrhythmias and are used in patients who remain at risk of recurrence of these arrhythmias.
    • Antiarrhythmic drugs.Antiarrhythmic drugs include lidocaine, procainamide, or amiodarone. Amiodarone or another antiarrhythmic drug may be used later to prevent subsequent arrhythmias.

    Treatment of other arrhythmias. People with atrial fibrillation are at high risk for stroke after a heart attack and should receive anticoagulants such as warfarin (Coumadin). There are also bradyarrhythmias (very slow rhythm disturbances) that often develop with a heart attack and can be treated with atropine or pacemakers.

    Medicines

    Aspirin and other antiplatelet agents

    Anticoagulants are used in all stages of heart disease. They are classified as antiplatelet agents or anticoagulants. They are used along with thrombolytics and to prevent heart attacks. Anticoagulant therapy is associated with the risk of bleeding and stroke.

    Antiplatelet drugs. They inhibit the adhesion of platelets in the blood and therefore help prevent blood clots. Platelets are very small and disc-shaped.They are essential for blood clotting.

    • Aspirin. Aspirin is an antiplatelet drug. Aspirin should be taken immediately after the onset of a heart attack. An aspirin tablet can either be swallowed or chewed. Better to chew an aspirin tablet – this will speed up its action. If the patient has not taken aspirin at home, it will be given to him in the hospital, then it must be taken daily. The use of aspirin in heart attack patients has been shown to reduce mortality.It is the most common antiplatelet agent used in people with cardiovascular disease and is recommended to be taken daily at a low dose on an ongoing basis.
    • Clopidogrel (Plavix) – refers to drugs of the thienopyridine series, this is another antiplatelet drug. Clopidogrel is taken either immediately or after percutaneous intervention and is used in patients with heart attacks and after initiation after thrombolytic therapy. Patients receiving a drug eluting stent should take clopidogrel with aspirin for at least 1 year to reduce the risk of blood clots.Patients hospitalized for unstable angina should receive clopidogrel if they are unable to take aspirin. Clopidogrel should also be given to patients with unstable angina pectoris for whom invasive procedures are planned. Even conservatively treated patients should continue to take clopidogrel for up to 1 year. Some patients will need to take clopidogrel on an ongoing basis. Prasugrel is a new thienopyridine that can be used in place of clopidogrel.It should not be used by patients who have had a stroke or transient ischemic attack.
    • Inhibitors of IIb / IIIa receptors. These are powerful blood-thinning drugs such as abciximab (Reopro), tirofiban (Aggrastat). They are given intravenously in a hospital and can also be used for angioplasty and stenting.

    Anticoagulants. They include:

    • Heparin is usually given during treatment with thrombolytic therapy for 2 days or more.
    • Other intravenous anticoagulants may also be used – Bivalirudin (Angiomax), Fondaparinux (Arixtra), and enoxaparin (Lovenox).
    • Warfarin (Coumadin).

    There is a risk of bleeding with all of these drugs.

    Beta-blockers

    Beta-blockers reduce the oxygen demand of the heart muscle, slow down the heart rate and lower blood pressure. They are effective in reducing deaths from cardiovascular disease.Beta blockers are often given to patients early in their hospitalization, sometimes intravenously. Patients with heart failure or who may develop cardiogenic shock should not receive intravenous beta blockers. Long-term oral beta-blocker therapy for patients with symptomatic coronary artery disease, especially after heart attacks, is recommended in most cases.

    These drugs include propranolol (Inderal), carvedilol (Koreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodin), metoprolol, and esmolol (Breviblock).

    Treatment of a heart attack. The beta blocker metoprolol may be given within the first few hours after a heart attack to reduce damage to the heart muscle.

    Preventive use after a heart attack. Beta blockers are taken orally on a long-term basis (as maintenance therapy) after the first heart attack to help prevent recurrent heart attacks.

    Side effects of beta blockers include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness.They can lower your HDL (“good”) cholesterol levels. Beta-blockers are divided into non-selective and selective drugs. Non-selective beta-blockers such as carvedilol and propranolol can cause bronchial smooth muscle contraction, leading to bronchospasm. Patients with bronchial asthma, emphysema or chronic bronchitis should not take non-selective beta-blockers.

    Patients should not abruptly stop taking these drugs. Stopping beta blockers abruptly can lead to a sharp increase in heart rate and high blood pressure.It is recommended to slowly reduce the dosage until the intake is completely discontinued.

    Statins and other lipid-lowering drugs that lower cholesterol

    After admission to the hospital for acute coronary syndrome or heart attack, patients should not interrupt statins or other drugs if their LDL (“bad”) cholesterol levels are elevated. Some doctors recommend that your LDL cholesterol should be below 70 mg / dL.

    Angiotensin-converting enzyme inhibitors

    Angiotensin-converting enzyme inhibitors (ACE inhibitors) are important drugs for the treatment of heart attack patients, especially those at risk of developing heart failure.ACE inhibitors should be given on the first day to all heart attack patients unless contraindicated. Patients with unstable angina or acute coronary syndrome should receive ACE inhibitors if they show signs of heart failure or signs of decreased left ventricular ejection fraction on echocardiography. These drugs are also widely used to treat high blood pressure (hypertension) and are recommended as first-line therapy for people with diabetes and kidney damage.

    ACE inhibitors include captopril (Capoten), ramipril, enalapril (Vasotec), quinapril (Accupril), Benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil).

    Side effects. Side effects of ACE inhibitors are rare, but may include coughing, an excessive drop in blood pressure, and allergic reactions.

    Calcium channel blockers

    Calcium channel blockers may provide relief in patients with unstable angina, whose symptoms are not relieved by nitrates and beta-blockers, or are used in patients who are contraindicated in beta-blockers.

    Secondary prevention

    Patients can reduce the risk of a second heart attack by following certain preventive measures that are explained when they leave the hospital. Compliance with a healthy lifestyle, in particular a certain diet, is important in preventing heart attacks and must be followed.

    Blood pressure. Target blood pressure numbers should be less than 130/80 mm Hg.

    LDL cholesterol (“bad” cholesterol) should be substantially less than 100 mg / dL.All patients who have had a heart attack should receive a statin recommendation before they are discharged from the hospital. It is also important to control your cholesterol levels by reducing your saturated fat intake to less than 7% of your total calories. You need to increase your intake of omega-3 fatty acids (fish, fish oil rich in them) to reduce triglyceride levels.

    Physical exercise. Duration 30-60 minutes, 7 days a week (or at least at least 5 days a week).

    Weight loss.Combining exercise with a healthy diet rich in fresh fruits, vegetables and low-fat dairy can help you lose weight. Your body mass index (BMI) should be 18.5-24.8. Waist circumference is also a risk factor for developing a heart attack. Waist circumference for men should be less than 40 inches (102 cm) for women less than 35 inches (89 centimeters).

    Smoking. It is absolutely important to quit smoking. In addition, exposure to tobacco smoke (secondhand smoke) should be avoided.

    Disaggregants. Your doctor may recommend that you take aspirin (75-81 mg) on ​​a daily basis. If you have had a drug eluting stent implanted, you should take clopidogrel (Plavix) or prasugrel (Effient) along with aspirin for at least 1 year after your surgery. (Aspirin is also recommended for some patients as a primary prevention of heart attack.)

    Other medicines. Your doctor may recommend that you take ACE inhibitors or beta blockers on an ongoing basis.It is also important to get a flu shot every year.

    Rehabilitation. Physical rehabilitation

    Physical rehabilitation is extremely important after a heart attack. Rehabilitation may include:

    • Walking. The patient usually sits in a chair on the second day, and begins walking on the second or third day.
    • Most patients have a low level of exercise tolerance early in their recovery.
    • After 8-12 weeks, many patients, even those with heart failure, experience the benefits of exercise.Exercise advice is also given at discharge.
    • Patients usually return to work after about 1–2 months, although the timing may vary depending on the severity of the condition.

    Sexual activity after a heart attack is very low risk and generally considered safe, especially for people who engage in it regularly. The feelings of closeness and love that accompany healthy sex can help offset depression.

    Emotional Rehabilitation

    Depression occurs in many patients with ACS and heart attack. Research shows that depression is a major predictor of mortality for both women and men. (One reason may be that depressed patients take their medications less regularly.)

    Psychotherapy, especially cognitive behavioral therapy, can be very helpful. For some patients, it may be advisable to take certain types of antidepressants.

    Information provided by the website: www.sibheart.ru

    90,000 INTERVIEWS Women are the unrecognized heroines of this crisis

    CJ: Last March, you expressed concern about increasing gender inequality. Why has the pandemic been particularly negative for women?

    FM: Women and men are not equal in the face of any crisis, and this one is no exception. Oftentimes, existing inequalities only intensify during these periods.The coronavirus pandemic has become an ordeal for women. They make up a significant proportion of those who are on the front lines of the fight against the virus and are at the highest risk of infection.

    UN-Women photo

    UN-Women Executive Director Fumzile Mlambo-Ngcuka

    In addition, they have been severely affected by the socio-economic consequences of the epidemic. The forced suspension of activities has led to a deterioration in the financial situation of women, who more often than men have volatile and low-paid jobs.Many women have lost their source of livelihood.

    In addition, a significant proportion of women receive support from social services. Given that quarantine has made social security agencies less accessible, women who were not registered with them before the crisis began to face even greater difficulties.

    Many do not realize that the main work to overcome the crisis lies on women’s shoulders.

    CY: The pandemic has highlighted the most important professions for the functioning of society – medical workers, cashiers, teachers.The proportion of women in them is disproportionately high. Can the current crisis force us to change our attitude towards those who work in these areas?

    FM: Women are the unrecognized heroines of this crisis. After all, oddly enough, it seems that even now many do not realize that the main work to overcome the crisis lies on women’s shoulders. They save lives by staying in the shadows. I sincerely hope that the situation will change. That is why it is extremely important to talk about the contribution of women – so that everyone understands its importance.

    CY: What can women contribute to overcoming this crisis?

    FM: Nursing has traditionally been considered to be an occupation for women – and they really make up the lion’s share of the medical staff. However, women, who in everyday life have to act in a wide variety of guises, are perhaps better able to see that this crisis goes far beyond health care and affects many other aspects of our lives – social, economic, health, food security.Women feel the interconnectedness of all these problems more subtly, as they face them every day. They are inherently better equipped to handle situations like this.

    CJ: In your April 2020 statement, you speak of an invisible pandemic, referring to the rise in violence against women. How has the isolation regime affected the status of women?

    FM: What I’m really talking about is that there has been an increase in calls to hotlines and domestic violence shelters around the world.Isolation has increased the amount of time partners spend with each other and thus fueled more conflicts in families. Some were trapped in the same room as the rapist, cut off from those who could help them. Moreover, reporting violence in an epidemic has also become more difficult, in particular due to limited access to hotlines and disruptions to government agencies such as the police, for example.

    Read also
    Many women have no control over their own destiny or their bodies, and the pandemic has only exacerbated their situation

    In countries where services for the assistance of victims of domestic violence do not fall into the category of basic services, women who have to spend all the time with their abuser have been completely deprived of support.

    CY: Should we be afraid of restricting women’s rights?

    FM: Yes, there is already a regression in women’s rights, and in the future the situation can only get worse. We must do everything to prevent this. This year marks the 20th anniversary of the adoption by the UN Security Council of Resolution 1325 on women’s rights, peace and security. We must in every possible way contribute to the implementation of plans in this area and prepare for even more active actions.Women’s rights should not be sacrificed to circumstances; they should remain a priority task for the world community. Winning this fight is just as important as overcoming the COVID-19 epidemic. We must emerge victorious from both of these battles.

    Women’s rights cannot be sacrificed to circumstances

    CJ: What needs to be done to prevent the negative impact of the crisis on women’s rights?

    FM: You need to act in several directions.On the economic front, we must ensure that anti-crisis measures include interventions that are directly targeted at women. At the same time, they should also cover women workers in the informal sector, for whose rights we continue to fight. Women and men are not equal in the face of any crisis.

    The fight against gender-based violence, which will not go away with the end of the crisis, should be continued. This question must not be overlooked. We must also encourage more women to take up leadership positions, especially in countries with a low proportion of women in leadership.In a number of areas – including but not limited to health – there is a need to ensure more equitable representation of women and men. This issue should remain the focus of our attention.

    Read also
    Rebooting after the crisis: women must be at the forefront and at the center of this process

    The development of distance learning should be encouraged, but careful to ensure that it is not accompanied by an increase in the digital divide. Technology is still not available in some communities, and even where it is, women are often less able to use it than men.We must continue to strive for equal access to technology and ensure that when education goes digital, girls from poor areas are not dropped out of the educational process and can enjoy digital education platforms on an equal basis with other segments of the population.

    I hope that UNESCO, UN Women, the Broadband Commission, the International Telecommunication Union and the ministries of education will join forces to bring high-speed internet to all rural schools and informal settlements and to ensure that everyone has access to education. wherever he is.

    90,000 basic rules, the choice of cosmetics, an overview of 8 products

    Two main groups of factors affect the condition of our skin: external and internal. External ones are, first of all, lifestyle, ecology, nutrition … That is, those factors that we can influence to prolong the youthfulness of the skin. Internal changes are inherent in nature itself: these are natural processes, which, alas, cannot be stopped. But it can be adjusted.

    Rules for anti-aging facial skin care

    Internal skin aging begins at the age of 20-25.It is from this moment that intracellular processes slow down: the skin needs more and more time to recover and renew itself. Problems accumulate like a snowball, wrinkles become more noticeable, the skin grows dull, loses its elasticity … Every ten years the intensity of negative changes increases, and along with them the needs of the skin change. That is why it is so important to select daily care not only by skin type, but also by age.

    Skincare after 30 years

    Got a noisy 30th birthday party behind? So it’s time to do a thorough check on the cosmetics shelves.From now on, your skin needs a little more attention and care. And also – deep hydration.

    • From the age of 30, the skin loses moisture more intensively.
    • Collagen and elastin synthesis is inhibited.
    • Facial wrinkles become more noticeable, nasolabial folds appear.

    How to care for your skin after 30 years?

    1. To stop the process of moisture loss, use a gentle foam or micellar water for cleaning.
    2. Do not neglect toners: they will help the skin to maintain its healthy color and enhance the effectiveness of the products in the next stages of care.
    3. Exfoliating should also be gentle. Large abrasives can damage the skin, so it is best to give preference to soft gommages or pilling.
    4. In addition to day and night moisturizers, use serum (applied before cream) and nourishing masks.
    5. Don’t forget about UV protection: SPF products will help you avoid the appearance of age spots.
    6. Pay special attention to products containing hyaluronic acid, peptides, vitamins and antioxidants.

    Skin care after 40 years

    Age Expert

    Face mask Age expert 45+

    More details

    After 40 years, internal changes in the structure of the skin become more noticeable:

    • the number of wrinkles increases;
    • Due to a decrease in the content of collagen and elastin, the skin sags, loses its elasticity;
    • dull skin tone;
    • Disruption of the sebaceous glands leads to increased dryness.

    Mature skin regenerates more slowly and becomes more sensitive to negative environmental factors.

    She needs care aimed at the regeneration of intracellular processes, protection and nutrition.

    1. It’s time to replenish your beauty arsenal with products with a lifting effect that will help maintain a clear face contour and restore skin elasticity.
    2. Look for denser anti-aging creams with oil-based SPFs.
    3. Gentle exfoliation will even out skin tone and remove dead skin cells.
    4. Among the essential components of care products are peptides, retinol, hyaluronic acid and antioxidants.

    Does your skin need anti-aging care? Take a virtual diagnosis and get a personal recommendation for skin care

    Skin care after 50 years

    Age Expert

    Face mask Age expert 55+

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    During menopause, hormones change and cellular metabolism slows down significantly.

    • Due to the inability of cells to retain moisture, the skin becomes dry, the effect of “corrugated paper” or “mesh” of wrinkles appears.
    • Collagen and elastin are synthesized too slowly: the skin loses its elasticity and sags.
    • Lack of lipids leads to dehydration and disruption of the skin’s natural protective barrier.
    • Age spots may appear.

    To correct age signs, it is important to use specialized products 50+: creams, serums and masks rich in lipids, oils and anti-aging ingredients (for example, retinoids and antioxidants).

    1. Use the most gentle products to cleanse and exfoliate the skin, and to moisturize and nourish – thick and rich textures.
    2. Cosmetics with brightening ingredients will help get rid of age spots, and products with a high SPF level will protect the face from the appearance of new ones.

    Features of anti-aging skin care around the eyes

    Revitalift Laser X3

    Anti-aging cream for the area around the eyes

    More details

    The skin around the eyes is especially sensitive to age-related changes: the content of collagen fibers in this area is minimal, and there are no sebaceous glands at all.Mimicry adds fuel to the fire: squinting or raising eyebrows in surprise, we stretch the skin and thereby provoke the appearance of the first mimic wrinkles.

    For more information on eye contour care:

    • Anti-wrinkle eye cream
    • Anti-wrinkle retinol cream

    What to do? Above all, keep smiling and expressing your emotions! The main problems that will have to be dealt with are wrinkles, dryness, hypersensitivity, laxity (the so-called “bags” under the eyes), dark circles and pigmentation.

    And proper anti-aging care will help slow down the aging process of the skin around the eyes.

    • Start caring for the skin around the eyes even before the first signs of aging appear – at the age of 20-25.
    • Use specialized cosmetics for the skin around the eyes – “normal” facial care is inappropriate here.
    • Before going outside, remember to apply protective eye cream with SPF and put sunglasses in your purse.

    The main stages of care – cleansing, moisturizing, nutrition, sun protection – are relevant for all ages.However, there are some peculiarities.

    Age Visible changes Leaving
    20+ Almost none. Feeling of dryness and tightness is possible Moisturizers with hyaluronic acid
    30+ Expressive wrinkles, loss of firmness Creams with denser textures based on antioxidants and nourishing oils
    40+ crow’s feet), puffiness, reduced firmness Anti-aging creams with regenerating ingredients (retinol, caffeine, etc.)etc.). Additional masks for the eyes
    50+ Deep wrinkles, bags and dark circles under the eyes are possible, sagging skin Products with a powerful lifting effect containing peptides and anti-aging ingredients. Complementary eye masks

    Types of anti-aging face cosmetics

    The modern beauty industry offers a variety of anti-aging skin care products. How not to get lost in them and choose exactly what you need? The main thing is to know the main tasks of each type of funds.

    Creams : day – for moisturizing, night – for regeneration and nutrition.

    Serums: to saturate the skin with concentrated beneficial ingredients, as well as smooth the surface.

    Masks: for specific tasks. For example, removal of puffiness, deep nutrition, cell regeneration, etc.

    Toners: for toning and additional moisturizing of the skin

    Oil complexes: for lipid replenishment and deep nutrition.

    And, of course, the common task of all anti-aging products is to fight wrinkles and other signs of aging of the facial skin.

    How to choose cosmetics for anti-aging skin care?

    We select cosmetics by age

    The rule of prevention does not work here, so you should not start using 50+ products with a powerful lifting effect at the age of 30. It will still not work to accumulate useful components “in reserve”.

    We select products by skin type

    1. For oily skin – water-based and with a minimum amount of oils.Salicylic acid and green tea extract will be helpful.
    2. For dry skin – on the contrary, with the maximum amount of oils in the composition. They will help restore the hydro-lipid balance of the skin and saturate it with vitamins.
    3. For sensitive skin – with gentle ingredients (eg retinal instead of retinol). This will help avoid irritation, increased dryness, and inflammation.

    Read the label

    Among the most effective components:

    • hyaluronic acid – moisturizes the skin, smoothes wrinkles;
    • vitamins C and E – antioxidants, promote collagen production and skin regeneration;
    • retinol (retinal) – reduces the number of wrinkles and other age-related signs of skin aging;
    • coenzyme Q-10 – fights free radicals and premature skin aging;
    • peptides – increase skin tone;
    • natural vegetable oils – deeply nourish, moisturize, saturate with useful components.

    Anti-aging face skin care: a review of products

    Age Expert day cream

    Due to the unique composition of the creams, created for different age groups, deeply affect the skin from the inside and solve the main problems:

    Line 35 + “- moisturizes for 24 hours, reduces the number of wrinkles, restores elasticity.

    Age Expert

    Day Cream Age Expert 35+

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    Line “45+” – restores skin elasticity, tightens facial contours and reduces the number of wrinkles.

    Age Expert

    Day Cream Age Expert 45+

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    Line “55+” – promotes the renewal of skin cells, even fights deep wrinkles, corrects the oval of the face.

    Age Expert

    Day anti-aging cream Age expert 55+

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    Line “65+” – fights pigmentation, reduces the number of wrinkles, improves facial contours, tightening the skin.

    Age Expert

    Day Cream Age Expert 65+

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    REVIEWS:

    Day Cream “Age Expert 45+” ​​

    “L’oreal Cream Age Expert 45+ day will be a good choice for owners of normal and slightly dry skin that needs basic care for the cold season.The cream will moisturize and nourish the skin, giving it elasticity. The cream is absorbed quite quickly and is suitable for makeup. ”

    VIVsovet, www.irecommend.ru

    Age Expert Night Cream

    Line 35+ – thanks to collagen biospheres, it smoothes wrinkles and fights the first signs of skin aging.

    Age Expert

    Night face cream Expert Age 35+

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    Line “45+” – stimulates skin regeneration at a deep level and restores elasticity, “pushing” wrinkles from the inside.

    Age Expert

    Night cream Age expert 45+

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    Line “55+” – tightens the oval of the face and intensively nourishes the skin due to the high content of valuable oils.

    Age Expert

    Night cream Age Expert 65+

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    Age Expert

    Night anti-aging cream Age expert 55+

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    Line “65+” – a cream formula enriched with a multivitamin complex, reduces the number of wrinkles and restores the natural glow of youth …Corrects the contours of the face, restores elasticity to the skin.

    REFERENCES:

    Night Cream “Expert Age 35+”

    “The cream is suitable for all skin types. It is, indeed, very quickly absorbed after application, even on my combination skin (oily T-zone) and does not leave oily. <…> The result suits me perfectly, the skin is smooth and radiant in the morning, I especially like the result of this cream on my neck, where I have small horizontal wrinkles (in common people, “circles of venus”).<…> Will I buy this cream again – YES! ”

    Kitykat, www.irecommend.ru

    Night Cream “Expert Age 45+” ​​

    “The cream is very light, but at the same time nourishing; Evens out the tone of the face; The skin has become more elastic, the appearance (for me) has improved markedly. I was very pleased, because for little money, I received a wonderful cream, which is in no way inferior to much more expensive analogues.

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