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Posterior t eet h
Canines 1st Premolars 2nd Premolars
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Radiographs (x-rays) showing tooth crowns covered with enamel, and the tooth roots embedded within the alveolar bone. You can distinguish the whiter outer enamel shape from the darker inner dentin, and the darkest pulp chamber in the middle of the tooth. The very thin, dark periodontal ligament can also be seen between the root and the bone, but the cementum cannot be seen. NO. LINGUAL CUSPS OR CINGULUM NO. OF LOBES
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Slightly shallower lingual crown concavity More even root taper facially and lingually
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Part 1 | Comparative Tooth Anatomy
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7. De Voto FCH, Arias NH, Ringuelet S, et al. Shovel-shaped incisors in a northwestern Argentine population. J Dent Res 1968;47:820. 8. Taylor RMS. Variations in form of human teeth: I. An anthropologic and forensic study of maxillary incisors. J Dent Res 1969;48:5â16. 9. Dahlberg AA. The dentition of the American Indian. In: Laughlin WS, ed. The physical anthropology of the American Indian. New York: The Viking Fund, 1949. 10. Snyder RG. Mesial marginal ridging of incisor labial surfaces. J Dent Res 1960;39:361.
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base made up of the buccal cusp ridges, and the apex is the lingual cusp tip as illustrated in red on Figure 4-24. On this symmetrical type of mandibular first premolar, it is more difficult to determine right from left by only looking at the occlusal design. The mesial and distal cusp ridges of the buccal cusp on the mandibular first premolars are nearly aligned in a straight line mesiodistally. The contact areas, as seen from the occlusal view, are at the point of broadest mesiodistal dimension just lingual to this line of the buccal cusp ridges. On the mandibular first premolar, the buccal ridge is not prominent, and the buccal crest of contour, like the buccal cusp tip, is slightly mesial to center. The crest of contour of the lingual surface is often distal to the middle mesiodistally of the tooth. On the two-cusp second premolars, the crown outline is round or oval shaped, but with a relatively square occlusal table. The crown outline tapers to the lingual, so the crown outline is more broadly curved on the buccal side than on the lingual side. The lingual cusp tip is often off center toward the mesial half of the crown. On the three-cusp second premolars, the occlusal outline is more nearly square than is the occlusal outline of the two-cusp type because its crown is wider lingually with two lingual cusps. When the lingual cusps are large, the occlusal surface is broader mesiodistally on the lingual half than on the buccal half (Fig. 4-21). This is an EXCEPTION to all types of two-cusp premolars in both arches that normally taper narrower toward the lingual. Further, more than half of the time, threecusp premolar teeth have greater faciolingual bulk in the distal than mesial half of the crown (tapering smaller from distal to mesial), which is an EXCEPTION to the normal taper to the distalHH (Fig. 4-21). Examples of differences in crown taper are seen on mandibular second premolars in Figure 4-19. A summary of the geometric outline shapes of premolars is presented in Figure 4-22. Dr. Woelfelâs Original Research Data
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MANDIBULAR MOLARS (proximal)
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Buccal views of maxillary and mandibular third molars. Notice the fused roots and long root trunks. The mesial surfaces all face toward the centerline. Notice the tremendous variation among the maxillary third molars. Observe the differences between maxillary and mandibular anatomy. Also, note the similarity of each to the first and second molars found within their respective arches. (Method of comparison and teeth furnished by Kelli Whapham, first-year Ohio State University dental hygiene student, 1978.) 7.5 11.8 10.8 18.2 11.3 9.2 10.1 8.9 0.4 0.2
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Part 1 | Comparative Tooth Anatomy
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1. PRIMARY CANINES FROM THE LABIAL VIEW a. Outline Shape of Primary Canines from the Labial View Maxillary canine crowns may be as wide as they are long. They are constricted at the cervix. They have convex mesial and distal outlines, with distal contours more rounded than mesial contours, which are somewhat angular (Fig. 6-13). Mandibular canine crowns, like permanent canines, are longer incisocervically than wide mesiodistally and are narrower mesiodistally than maxillary canine crowns (Appendix 9g).G Cusp Ridge Outlines of Primary Canines from the Labial View: Maxillary canine cusps are often very sharp (pointed) meeting at an acute angle. The cusp ridges of these maxillary canines are UNIQUE in that the mesial cusp ridge is longer than the distal cusp ridges (similar to only the permanent maxillary first premolars, but just the opposite of all other premolars and canines, permanent and primary) (Appendix 9h, maxillary canine, and Fig. 6-13B). The mesial cusp ridges are less steeply inclined8 than the shorter distal ridges. Mandibular
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No real bone loss and no attachment loss in furcation Definite bone loss or attachment loss
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Type II Scanning electron photomicrograph of the pulp chamber floor of a maxillary molar with four canal orifices identified for orientation: the palatal (P), distobuccal (DB), and the two orifices into the mesiolingual root called mesiobuccal (MB) and mesiolingual (ML, arrow). (Original magnification Ã20.) (Courtesy of Dr. James Gilles and Dr. Al Reader.)
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Movement between the heads of the condyles of the mandible and the inferior surface of the discs occurs within the lower joint spaces. In the lower joint space, only a hinge-type or rotary motion occurs around a hinge axis line. That is, the body of the mandible D. TOTAL JOINT MOVEMENT
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and has maintained a stable and comfortable mandibular position for at least 1 week.43 Next, the leaf gauge is inserted in the wafer, and an impression material is thinly spread over tooth indentations in the leaf wafer (Fig. 9-35D). Then the entire assembly is carried to the mouth (Fig. 9-35E), and the patient closes firmly, as previously, onto the leaf gauge until the recording medium sets. The imprints of the upper and lower teeth in this centric relation registration (Fig. 9-35F) are used to relate casts of each arch mounted on the articulator (Fig. 9-35G). This diagnostic mounting procedure should always be accomplished prior to attempting any type of tooth equilibration in the mouth.18,19,22 These dental stone casts, mounted in their relaxed centric relation position, can be used to determine the extent of tooth reshaping required in order to decide the best treatment. The dental stone teeth with interfering or premature contacts can be reshaped (reduced) in order to predict the amount of tooth reduction that will be required during the equilibration. If the amount of tooth structure that must be removed during the equilibration would likely expose dentin or pulp, then orthodontics or surgical procedures must be considered. Another device used for anterior deprogramming of the mandible and for recording centric jaw relation is the sliding guiding inclined gauge or sliding guide40â44 (Fig. 9-36). It comes in three maximum thicknesses, and the thickness used is dependent on the severity of the malocclusion (Fig. 9-36A). The thickness gradually increases from tip to handle, and the curvature of the sliding guide is critical, so that it can be placed in the mouth between overlapping incisors at a relatively steep angle relative to the plane of occlusal without injuring the tissue of the roof of the mouth (Fig. 9-36B). The exact thickness between the incisors is read on the millimeter scale (Fig. 9-36C). Minimal incisal separation is the goal for deprogramming and jaw position registration, just so long as no posterior teeth touch, thus avoiding proprioceptive impulses. This is particularly important for the centric jaw relation registration to
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INCISAL ANGLE (CENTRAL INCISORS) CANINE RISE ANGLE RIGHT SIDE LEFT SIDE additional retention gained from the enamel etching and bonding, there is less need for internal retention grooves. For cast metal or porcelain inlays or onlays, opposing buccal and lingual walls must diverge slightly toward the occlusal (seen on a die for a cast metal onlay in Fig. 10-24), and the two axial walls in a mesioocclusodistal inlay preparation must converge slightly toward the occlusal. This is necessary so that an accurate restoration can be refined outside of the mouth and then be seated within the tooth preparation in the mouth.
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List and describe as many anomalies you can that you are likely to see in the maxillary incisor area of the mouth. Chapter 12 | Forensic Dentistry
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central incisors. This papilla is located over the incisive foramen, where the nasopalatine nerve passes from the nasal cavity onto the palate to innervate the anterior portion of the hard palate. It is the location for injecting anesthetic to numb palatal tissue in this area.B The palatine raphe [RAY fee] is the slightly elevated ridge of firm tissue running anteroposteriorly along the midline of the hard palate (over the intermaxillary suture attachment between the palatine processes of the right and left maxillae) (Fig. 15-22). The mucosa over the raphe is firmly attached to the underlying bone without intervening fat or gland cells. The rest of the tissue on both sides of the raphe has fat or salivary gland
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n. Mandibular first premolar buccal cusps are more pointed (110 degrees) versus on second premolar, where they are more obtuse or blunt (130 degrees) (facial views). o. Mesial proximal contacts (and marginal ridges) of mandibular second premolars are more occlusal than distal contacts (following the general rule), whereas the reverse is true on mandibular first premolars (EXCEPTION), where mesial contacts (and marginal ridges) are more cervical (facial views). p. Lingual cusps of mandibular first premolars are very small and nonfunctional. On second premolars, the lingual cusps function and are relatively longer (proximal views). q. Lingual cusp tips of mandibular second premolars are positioned to the mesial (or, if there are two lingual cusps, the mesiolingual is the more prominent) (lingual views). r. Mandibular first premolars have a mesiolingual groove separating the mesial marginal ridge from the lingual cusp. Second premolars (three-cusp type) have a lingual groove separating the two lingual cusps (lingual and mesial views). s. Mesial marginal ridges of first premolars slope cervically toward the lingual at about 45 degrees from horizontal. On second premolars they are more horizontal (mesial views). t. The mesial root surfaces of mandibular second premolars are the only premolar root surface (maxillary and mandibular, mesial and distal) not likely to have a midroot depression (best seen on models or actual teeth, not labeled in drawings). u. Mandibular first premolars are the only premolars that have the mesiolingual corner, with its mesiolingual groove and low marginal ridge, pinched or squeezed in, forming about a 45-degree angle with the lingual surface. This makes the occlusal outline somewhat diamond shaped (occlusal views). k
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Includes a fourth factor, time to the still existing concept of Keyes, depicting the significance of changes taking place over a period. Caries is a multifactorial disease in which there is interplay of four primary factors : Host Microbial flora Substrate Time Thus, caries require a susceptible host, a cariogenic flora, and a suitable substrate that must be present for a sufficent time.
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Morphology of CEJ
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Relations Peritoneal cavity
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The urethra The male urethra (Fig. 87b)
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Fig. 135âThe wrist, carpal and carpometacarpal joints in section.
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The axillary nerve Damage to the main trunk of the radial nerve results in a wrist drop due to paralysis of all the wrist extensors (Fig. 144). Damage to the posterior interosseous nerve, however, leaves extensor carpi radialis longus intact, as it is supplied from the radial nerve above its division; this muscle alone is sufï¬ciently powerful to maintain extension of the wrist. The disability produced by a wrist drop is inability to grip ï¬rmly, since, unless the ï¬exor muscles are stretched by extending the wrist, they act at a mechanical disadvantage. Try yourself to grip strongly with the wrist ï¬exed and realize how, by operative fusion of the wrist joint in extension, the weakness produced by a radial nerve paralysis would be overcome. Nerve overlap means that division of the radial nerve produces only a small area of anaesthesia of the dorsum of the hand between the 1st and 2nd metacarpals.
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The bones and joints of the lower limb
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The adductor canal (of Hunter) or subsartorial canal (Fig. 177)
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The deep peroneal nerve pierces extensor digitorum longus, then descends, in company with the anterior tibial vessels, over the interosseous membrane and then over the ankle joint. Medially lies tibialis anterior, while laterally lies ï¬rst extensor digitorum longus, then extensor hallucis longus. Its branches are: â¢ââmuscular â to the muscles of the anterior compartment of the leg â extensor digitorum longus, extensor hallucis longus, tibialis anterior, peroneus tertiusâand extensor digitorum brevis; â¢ââcutaneous â to a small area of skin in the web between the 1st and 2nd toes. Clinical features
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The pons External features (Fig. 240)
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The brain
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Fig. 246âThe thalamus and 3rd ventricle in coronal section. Clinical features
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Fig. 249âThe long ascending pathways of the dorsal columns (yellow lines) and spinothalamic tracts (red lines).
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particularly the basal ganglia, actually control movement by altering activity in the premotor cortex and, thus, the pyramidal motor projections. This clearly emphasizes the blur between the two systems. Components of the extrapyramidal system include the red nuclei, vestibular nuclei, superior colliculus and reticular formation in the brain stem, all of which project via discrete pathways to inï¬uence spinal cord motor neurons. Cerebellar projections (see page 344) are also included since they inï¬uence not only these brainstem motor pathways, but also the motor cortex itself via the dentatothalamic projection. Perhaps the most important structures to retain an extrapyramidal deï¬nition are the basal ganglia (see pages 353 and 354). The neostriatum (caudate and putamen) receives widespread cortical afferents, including those from high order sensory association and motor areas, and projects mainly to the globus pallidus. The latter nucleus is the major outï¬ow for the basal ganglia and, via the ventral anterior thalamus, exerts its major inï¬uence on premotor and hence the motor cortices. This pattern of connections suggests that the basal ganglia are involved in complex aspects of motor control, including motor planning and the initiation of movement. A variety of motor disorders are associated with basal ganglia pathology and, in some instances, neuroanatomically discrete deï¬cits in speciï¬c neurotransmitters. For example, Parkinsonâs disease involves the degeneration of dopaminergic neurons in the substantia nigra in the midbrain. This pigmented nucleus provides the neostriatum with a dense dopaminergic innervation which may be completely lost in severe cases of Parkinsonism. Knowledge of this selective chemical neuropathology has resulted in the development of a treatment of the disease which involves the oral administration of the dopamine precursor l-dopa. Clinical features
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The central nervous system
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Clinicianâs Pocket Reference, 9th Edition
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Example: 10.1 11,000 30.5 Pregnancy, menopause (physiologic or premature), severe illness, weight loss, stress, athletic training, âphysiologically delayed puberty,â anatomic (imperforate hymen, uterine agenesis, etc), gonadal dysgenesis (Turnerâs syndrome, etc), hypothalamic and pituitary tumors, virilizing syndromes (polycystic ovaries, idiopathic hirsutism, etc). Amenorrhea is categorized as primary (never had menses) or secondary (cessation of menses).
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disease; PID; pregnancy; breast lesions; and benign abdominal masses (teratomas) ⢠Adult male <1.2 mg/dL (SI: 106 mmol/L) ⢠Adult female <1.1 mg/dL (SI: 97 mmol/L) ⢠Child 0.5â0.8 mg/dL (SI: 44â71 mmol/L) ⢠To convert mg/dL to µmol/L, multiply by 88.40 ⢠Collection: Tiger top tube A clinically useful estimate of GFR. As a rule of thumb, serum creatinine doubles with each 50% reduction in the GFR. Creatine clearance is discussed in Chapter 6.
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⢠Normal = negative ⢠Collection: Tiger top tube ⢠See also Human Immunodeficiency Virus Testing, page 75 Used to diagnose recent acute HIV infection; becomes positive earlier than HIV antibodies. Decreases âwindowâ period. Can be positive as early as 2â4 weeks but becomes undetectable during antibody seroconversion (periods of latency). With progression of disease, P-24 usually becomes evident again. Used to screen blood donors
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Increased: Collagen-vascular diseases (RA, SLE, scleroderma, polyarteritis nodosa, 4
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Blood Collection Blood Smears: Wrightâs Stain Normal CBC Values Normal CBC Variations Hematocrit Three-Cell Differential Count The âLeft Shiftâ Reticulocyte Count CBC Differential Diagnosis Lymphocyte Subsets RBC Morphology Differential Diagnosis WBC Morphology Differential Diagnosis Coagulation and Other Hematologic Tests
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Abbreviations: WBC = white blood cell; hpf = high-power field.
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A CBC panel generally includes WBC count, RBC count, hemoglobin, hematocrit, MCH, MCHC, MCV, and the RDW and platelets. The differential is usually ordered separately. Normal CBC, differential, and platelet values are outlined in Tables 5â2 and 5â3.
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34 As above 38 39 42 59 61 56 24â41 24
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Increased: Heparin therapy, plasmaâclotting factor deficiency (except Factors VII and
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GRAM-NEGATIVE BACILLI Providencia spp. Pseudomonas aeruginosa Salmonella spp. Serratia spp. Serratia marcescens Shigella spp. Stenotrophomonas (Xanthomonas) maltophilia Vibrio cholerae (cholera) Yersinia enterocolitica Yersinia pestis (bubonic plague) Lactose-negative, oxidase-negative Lactose-negative, oxidase-positive blue-green pigment Lactose-negative, oxidase-negative Lactose-negative, oxidase-negative Lactose-negative, oxidative-negative, red pigment Lactose-negative, oxidase-negative Lactose-negative, oxidase-negative Gram-negative bacilli Gram-negative bacilli Gram-negative bacilli
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7 TABLE 7â3 Pathogens and Drugs of Choice for Treating Common Viral Infections* Viral Infection Determine if the numbers fit. [Î + ] = 24 Ã pCO 2
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shorter than the wire supplied with the triple-lumen catheter. This is most critical when exchanging a triple-lumen for a single-lumen catheter; use the longer triplelumen wire and insert the wire into the brown port. Place Shiley catheters using the Seldinger wire technique. Attach the catheter to the appropriate IV solution, and place the IV bottle below the level of the deep-line site to ensure a good backflow of blood into the tubing. If no backflow occurs, the catheter may be kinked or not in the proper position. Securely suture the assembly in place with 2-0 or 3-0 silk. Apply an occlusive dressing with povidoneâiodine ointment. Obtain a chest x-ray film immediately to verify placement of the catheter tip and to rule out pneumothorax. Ideally, the catheter tip lies in the superior vena cava at its junction with the right atrium, at about the fifth thoracic vertebra. Malpositioned catheters that go into the neck veins may be used only for saline infusion and not for monitoring or TPN infusion. Catheters that cannot be manipulated at the bedside into the chest can usually be positioned properly in the interventional radiology suite with the aid of fluoroscopy.
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Clear Clear Clear or turbid Ͼ1.016 Ͼ3 g/100 mL Ͼ0.5 Ͼ0.6 Ͼ200 IU Ͼ1 Yes Ͼ1000/mm3 Ͼ2500/mm3 PMNs early, monocytes later Ͼ100 RBC/mm3
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Laboratory Use SST brand tube for serum demonstrations in chemistry. Tube inversions ensure mixing of clot activator with blood and clotting within 30 min PST brand tube for plasma determinations in chemistry. Tube inversions prevent clotting For serum determinations in chemistry, serology, and blood banking. For stat serum determinations in chemistry. Tube inversions prevent clotting, usually in less than 5 min For trace element, toxicology, and nutrient determinations. Special stopper formulation offers the lowest verified levels of trace elements available. (See package insert) For plasma determinations in chemistry. Tube inversions prevent clotting (continued )
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The purpose of a surgical hand scrub is to decrease the bacterial flora of the skin by mechanically cleansing the arms and hands before the operation. Key points to remember: (1) If contamination occurs during the scrub, it is necessary to start over, and (2) In emergency situations exceptions are made to the time allowed for scrubbing (as in obstetrics, when the baby is brought out from the delivery room and the student is still scrubbing!). Caps and masks should be properly positioned before the start of the scrub. of the skin edges gives the best results (Figure 17â1). Figures 17â2 through 17â6 illustrate the commonly used suturing patterns. These include the simple interrupted suture (Fig. 17â2), running (locked or unlocked) suture (Fig. 17â3), vertical mattress suture (Fig. 17â4), horizontal mattress suture (Fig. 17â5), and subcuticular suture (Fig. 17â6).
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17 Suturing Techniques and Wound Care
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Atrial flutter with atrioventricular (AV) block (3:1 to 5:1 conduc-
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Second-degree AV block, Mobitz type I (Wenckebach), with 4:3 FIGURE 19â35 Sinus bradycardia, J-point elevation with ST-segment elevation and prolonged QT interval (0.56 s) in a patient with hypothermia.
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20 a single transit time through the circulation. Thus, the AâVO2 difference is a function of (1) PaO2, (2) Hgb, (3) CO, and (4) tissue O2 consumption. ⢠If cardiac output is low. Transit time is long and the tissues extract large amounts of oxygen during a single circulation time. Thus, the oxygen content of mixed venous blood is low and the AâVO2 difference is large ⢠If cardiac output is high. Circulation time is shorter and the amount of oxygen extracted is low. Consequently, the AâVO2 difference is low
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1. 2. 3. 4. Treat the cause of sepsis (parenteral antibiotics, drainage of abscess). Administer fluids to increase filling pressures. Increase vascular resistance (pressors such as dopamine). Provide inotropic support of the heart as needed.
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Diagnosis of Pulmonary Embolus
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(100 mL diluent +25 mL drug) D5W or PSS Dobutamine (Dobutrex) 500 mg 250 mL
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3. Check apical pulse. If absent or if <60 bpm and perfusion is poor, compress at a rate of 120/min. Wrap your hands around infantâs chest and compress ¹ â â³ â in. with thumbs side by side at the midsternum. 4. The compression/ventilation ratio is 3:1 for intubated newborn with two rescuers. Discontinue compressions when rate reaches 80 bpm or greater. No
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3,4 Amiodarone ⢠150 mg IV bolus over 10 minutes or Lidocaine ⢠0.5 to 0.75 mg/kg IV push Then use ⢠Synchronized cardioversion INDICATIONS: Severe metabolic acidosis (documented or following prolonged arrest) unresponsive to oxygenation and hyperventilation, hyperkalemia, tricyclic antidepressant toxicity DOSAGE: Adults. 8.4% 1 mEq/mL in 10- or 50-mL syringe, 4.2% 0.5 mEq/mL in 10-mL syringe. Peds. 1 mEq/kg. Dose may be calculated to correct ¹ â â ¹ â of base deficit.
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Acetic Acid And Aluminum Acetate (Otic Domeboro) 22 Commonly Used Medications
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Prevention and Rx of RDS in premature infants Replacement of pulmonary surfactant 100 mg/kg administered via endotracheal tube. May be repeated 3 more à q6h for a max of 4 doses/48h SUPPLIED: Suspension 25 mg of phospholipid/mL NOTES: Administer via 4-quadrant method Depression, adjunct to smoking cessation Weak inhibitor of neuronal uptake of serotonin and norepinephrine; inhibits the neuronal reuptake of dopamine DOSAGE: Depression: 100â450 mg/d ÷ bidâtid. Smoking cessation: 150 mg/d for 3 d, then 150 mg bid for 8â12 wk SUPPLIED: Tabs 75, 100 mg; SR tabs 100, 150 mg NOTES: Associated with seizures; avoid use of alcohol and other CNS depressants
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Quinolone antibiotic; inhibits DNA gyrase, antiinflammatory Instill 1â2 gtt in eye(s) q2h while awake for 2 d, then 1â2 gtt q4h while awake for 5 more d SUPPLIED: Soln 3.5 mg/mL
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Potassium Idodide [Lugolâs Solution] (SSKI, Thyro-Block) 10â40 mg PO hs Tabs 10, 20, 40 mg NOTES: Avoid concurrent use with gemfibrozil. Follow LFTâs
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Quinidine (Quinidex, Quinaglute) Type 2 DM Stimulates insulin release from pancreas 0.5â4 mg ac SUPPLIED: Tabs 0.5, 1, 2 mg
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Clinicianâs Pocket Reference, 9th Edition Reduces the risk of thrombotic stroke Platelet aggregation inhibitor DOSAGE: 250 mg PO bid SUPPLIED: Tabs 250 mg NOTES: Administer with food; may cause neutropenia, monitor WBC and LFTs
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620 Estrogen (µg)*
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Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl estradiol estradiol estradiol estradiol estradiol (35, (30, (35, (30, (30, 35, 40, 35, 40, 40, 35) 30) 35) 30) 30)
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Fluocinolone acetonide 0.025% Fluocinolone acetonide 0.2% Fluocinonide 0.05%
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Trough: just before next dose (levels drawn earlier than 6 h after a dose will be artificially elevated) Trough: just before next dose Trough: just before next dose Steady-state levels are usually achieved after 6â12 h Trough: just before next oral dose Osteopathic considerations in neurology
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Figure 9 Workersâ compensation (WC) data, showing cost-efficacy of the osteopathic approach. Data compiled by Labor and Industry computers in Florida and Colorado spinal facilitation and significant peripheral pathophysiological change47,125 resulting in significant tissue texture abnormalities. Similarly, many primary visceral afferent fibers affecting the spinal cord have the characteristics of nociceptive fibers. They produce neuropeptides such as substance-P and calcitonin gene-related polypeptide and respond to nociceptive stimuli. Some are even capable of eliciting a neurogenic inflammatory response in the surrounding tissue126,127. Thus, both somatic and visceral conditions are capable of creating musculoskeletal clues palpable as somatic dysfunction. From a diagnostic perspective, palpation for somatic dysfunction in patients with visceral disorders is one of the hallmarks of the osteopathic approach13. Relatively consistent palpatory findings are present, because visceral disorders stimulate afferents that, in turn, result in progressive and distinctive findings of secondary somatic dysfunction according to the autonomic innervations and sidedness of the involved viscus (Figure 12). Progression in the early visceral phase tends to be vague, poorly localized and midline over the appropriate collateral ganglion. As the visceral condition progresses, somatic clues are added in the form of paraspinal tissue texture changes (more so than restricted motion), Chapmanâs intercostal reflexes and rib somatic dysfunction. By the time that the visceral problem ruptures or irritates adjacent visceral pleura/peritoneum, the peritoneocutaneous reflex localizes over
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Licensed states in the USA Alaska Arizona Connecticut Hawaii Kansas Maine Montana New Hampshire Oregon Utah Vermont Washington Puerto Rico Virgin Islands X X X X X X X X X X X X X X X* X X
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of Hahnemannâs philosophy, the history of practice in the USA, FDA regulations and a review of the systematic reviews76. The authors concluded that, although there is a lack of conclusive evidence of the effectiveness of homeopathy for most conditions, they held that while âhomeopathy deserves an open-minded opportunity to demonstrate its value by using evidence-based principlesâ¦it should not be substituted for proven therapiesâ. The authors reported that there was evidence from randomized controlled trials that homeopathic remedies may be effective for the treatment of influenza, allergies, postoperative ileus and childhood diarrhea, while it was ineffective for delayed-onset muscle soreness and the prevention of influenza and migraine. Other investigators suggested that the evidence with regard to migraine was inconclusive77,78. For other neurological conditions, the evidence for the effectiveness in specific disorders is sparse. A Cochrane review on the efficacy of homeopathy for dementia79 concluded that there were no studies that fulfilled inclusion criteria (randomized controlled trials with a sample size of 20 or more) for review. Chapman and coworkers80 performed a randomized, doubleblind, placebo-controlled trial of homeopathy in 60 patients with mild traumatic brain injury (MTBI) showing a trend of improvements in the Difficulty with Situations Scale and the most common symptoms of MTBI. A trial of a homeopathic combination versus betahistine hydrochloride in vertigo showed an equivalence of outcomes81. Physical medicine Naturopaths are trained in spinal and extremity manipulation (similar to chiropractic and osteopathic manipulation), massage, physiotherapy, electrotherapy and hydrotherapy techniques. These are the interventions of the medical specialty of psychiatry. Hydrotherapy is the use of water to detoxify the body, stimulate a healing response and strengthen the immune system. Colonics, alternating hot and cold applications, and hyperthermal baths are included. There have been few reasonably rigorous trials of the interventions of physical medicine (except for manipulation) other than in post-stroke rehabilitation. Chiropractic manipulation is addressed elsewhere in this book (Chapter 3). Psychological counseling Naturopaths are trained in basic psychological counseling and stress management. Some naturopathic schools offer training in techniques such as biofeedback and visual imaging. The training also includes the importance of issues of spirituality and personal meaning. The most frequent uses of psychospiritual interventions in naturopathic medicine for neurological disorders are related to inducing behavioral changes that are supportive of health. These types of behavioral changes encourage the patient to be more selfempowered about their health by suggesting the use of coping skills that the patient may already have in place (e.g. spiritual practice, prayer) or by introducing interventions that are the patient can easily use on their own (e.g. journaling, deep breathing, short meditation). The physical effects of emotional states are increasingly documented in the literature of psychoneuroimmunology. Still, there are few trials showing effective intervention in most neurological disorders. PRAGYA APARADH AND THE BASIS OF ILLNESS The normal functioning of the physiology on the basis of balance of the doshas, the production of ojas, balanced dhatus and agnis and clear shrotas is, from a Vedic perspective, the normal state of the physiology. This is the state of human physiology that is able to reflect its infinite, unbounded source, the unified field underlying physiology, which we have previously identified as Consciousness. Less than perfect functioning of physiology is considered a result of less than perfect expression of Consciousness into matter or, more specifically, human anatomy and physiology. In Vedic terms, we speak of a âforgettingâ of the underlying unity of the unified field, once it has diversified to form human physiology. This âforgettingâ is evident on all levels of physiology, from the molecular level to the conscious level of the mind. How does this âforgettingâ occur? In the manifestation of human physiology from the unified field, the ability to distinguish and discriminate develops, and is referred to in Vedic terms as the intellect, or âbuddhiâ. It is the intellect that loses sight of the unified field and identifies with the ever-changing relative values of physiology instead. This forgetting, referred to as âpragya aparadhâ, is considered the primary cause of derangements in physiology leading to disease. These derangements involve the doshas, shrotas, agnis and dhatus, the lack of ojasâthe finest product of
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the anterior cingulated cortex (ACC), brainstem and thalamus contribute to the experience of being hypnotized. Brain activity differences associated with hypnotic ability With improved measures of hypnotic responsiveness, researchers have increasingly favored examinations of the relationship between brain functioning and hypnotizability. Thus, rather than attempting to identify qualitative and quantitative shifts in brain activity as a result of the hypnotic state, they have focused on demonstrating differences in brain activity between subjects of varying levels of hypnotic susceptibility. A number of recent studies41â43, have demonstrated a strong connection between hypnotic susceptibility and EEG theta activity, in that outside of hypnosis âhigh hypnotizablesâ show substantially greater mean theta power than âlow hypnotizablesâ, with data pointing to larger EEG theta differences in the more frontal areas of the cortex. It is argued that this elevated theta activity may reflect the high hypnotizable participantâs ability to narrowly focus attention and ignore competing stimuli44. Brain activity associated with responses to specific hypnotic suggestions The phenomenon of hypnosis is most powerfully demonstrated by subjectsâ responses to specific suggestions during hypnosis. In light of this, it has been argued that brain imaging studies of hypnosis should focus less on the state of hypnosis as a whole and more on the examination of physiological changes associated with specific hypnotic suggestions8. In one such study investigating hypnotically suggested positive auditory hallucinations, researchers demonstrated that, when subjects heard a sentence or hypnotically hallucinated hearing the sentence, their brain activity was quite different from that during quiet baseline or when simply imagining the words being spoken45. PET scans were used to measure changes in cerebral blood flow as subjects listened to a taped message that read âThe man did not speak often but when he did, it was worth hearing what he had to say.â For the imagination condition, subjects were instructed to imagine âas vividly as possible, hearing the same manâs voice repeating the phrase over and over againâ, and for the hallucinating condition they were again instructed to listen to the taped message, but the tape recorder was not played. As subjects heard the real recording, and during the hypnotic hallucination of the recorded message, increased activation of a region in the right anterior cingulate was shown. Additionally, subjective ratings of the vividness of the hallucination (âclarityâ) and the extent to which the voice was experienced as coming from outside of their head (âexternalityâ) were strongly correlated with the rCBF response (r=0.85 and r=0.95, respectively). One additional finding from this study should be noted: high hypnotizables who could readily hallucinate showed quite a different brain profile from equally high hypnotizables who were not good at hallucinating, thus adding support to the notion that hypnosis is not âjust one thingâ. Other PET-based research46 has examined the brain processes involved in hypnotic visual hallucinations. Highly hypnotizable subjects were presented with a colored and a gray-scale pattern. Activity in the fusiform/lingual region (related to the perception of color) was shown when subjects were asked simply to perceive color as color versus
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239 References
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14 Complementary and alternative medicine treatment of back and neck pain
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impairment64. More detailed information from clinical studies is needed to solve this controversy. Marijuana Cannabis sativa is occasionally recommended for the treatment of epilepsy18. Gowers reported about its use in the 19th century and prescribed it himself sometimes65. The recent conflicting evidence regarding marijuana and epilepsy has been reviewed by Gordon and Devinsky66. They reported that animal studies showed both anticonvulsant and proconvulsant effects of the primary psychoactive constituent â-9tetrahydrocannabinol (THC), and mild anticonvulsant effects of cannabidiol, the primary non-psychoactive constituent. Clinical data are inconclusive about the overall usefulness of marijuana for the treatment of epilepsy. Traditional Chinese medicine Acupuncture Within the context of TCM, acupuncture aims to restore the flow of life energy (Qi) along the meridians of the body. Some acupuncture points recommended for the treatment of epilepsy are reportedly similar to those for aggression4. Kloster and colleagues67 reported a well-designed randomized study in 39 patients with chronic intractable epilepsy. Acupuncture was applied by two professors of acupuncture from the Shanghai University of Traditional Chinese Medicine to the points LR3, LI4 and GV20 in addition to points indicated by individual TCM diagnosis. The study included a control group with sham acupuncture at points that were considered ineffective. No difference was found between the two groups (see Table 2). In a separate study with 34 chronic intractable epilepsy patients, no effect of acupuncture on quality of life as measured by the standard QOLIE-89 was found68. Zhenxianling Prescriptions in Chinese medicine are commonly a mixture of many ingredients. One example is Zhenxianling69, which consists of herbal tablets including valerian, antelopeâs horn powder, human placenta and seven other ingredients, and also of a plaster placed on the umbilicus, which includes semen strychni, semen hyoscyami and Cynanchum otophyllum and five other ingredients. This prescription was used in 239 patients with 95.4% having a reduction in seizure frequency by at least 50% (see Table 2). Regarding the interpretation of such results I am cautioned by a Western practitioner of TCM that physicians in Chinese hospitals are under significant pressure to produce positive research results. Qingyangshen Another herbal treatment for epilepsy in Chinese medicine is Qingyangshen prepared from the root of Cynanchum otophyllum. Kuang and co-workers70 (Table 2) reported on the effects of Qingyangshen as an adjunctive treatment in 32 patients with grand mal seizures that were refractory to conventional treatment. Of the 32 patients, 28 showed at 401
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Complementary therapies in neurology Reference Design Treatment (no. days of (daily valerian) dose)
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sleep latency and quality improved particularly with poor sleepers SUPPLEMENTS The evidence for the efficacy of melatonin in treating insomnia consists of a number of small placebo-controlled trials including at least five that were randomized. Two had negative results46,47, while three others reported improvements in several sleep parameters
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433 Complementary therapies in neurology
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Figure 3.5 3D view of the mid-brain demonstrating the important features of the limbic system involved in the perception of pain.
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receptors for glutamate are NaÏ© selective ion channels, which, when glutamate binds, produce short-lived (ϳ2 ms) post-synaptic depolarizations. In response to a noxious stimulus glutamate is released, AMPA receptors are activated and action potentials are generated in second order and projection neurones, transmitting the stimulus to higher centres. This is a fast and faithful transmission of the nociceptive information (Figure 5.2(a)). The NMDA receptor differs from the AMPA receptor in that, when activated it passes a large Ca2Ï© inï¬ux, in contrast with the AMPA and other glutamate receptors. Consequences of unchecked elevated Ca2Ï© could be severe, so the channel is tightly regulated. It is blocked by Mg2Ï© ions at physiological membrane potentials, the block only being released during sustained membrane depolarization. So, during the situation described above when the AMPA receptor is active, although the released glutamate will still be binding to the NMDA receptor, the channel cannot open to pass Ca2Ï© ions. In the presence of a more persistent noxious stimulus, peptides are released along with glutamate from afferent ï¬bre terminals. This delay in peptide release occurs partly because peptides are located in terminals of high-threshold C-ï¬bre afferents, but also because neuropeptide vesicles are stored at some distance from release sites, ensuring that peptides may not be released from the afferent ï¬bre terminal except in conditions of high frequency stimulation and signiï¬cant Ca2Ï© entry. The tachykinins and CGRP are the predominant excitatory peptide transmitters in the DH. There are three tachykinin peptides â SP, neurokinin A (NKA) and neurokinin B (NKB) â which prefer the tachykinin receptors NK1, NK2 and NK3 respectively (although a large degree of cross-afï¬nity exists). SP and the NK1 receptor have been studied in more detail than the others. Most spinal cord neurones that respond to SP are in lamina I and express NK1 receptors. These SP-responsive neurones are not absolutely required for normal responses to acute noxious stimuli, but they are needed for the generation of spinal hyper-excitability and manifestation of behavioural inï¬ammatory hyperalgesia. Many behavioural and electrophysiological pharmacological studies using NK1 receptor antagonists have revealed a role for SP in generating spinal hyper-excitability. However, despite this convincing pre-clinical evidence that SP and its receptors form an important part of the nociceptive pathway, NK1 receptor antagonists have been disappointing in human trials for analgesia in a variety of clinical pain states.
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Ligand: General term for a molecule (peptidic, chemical, ionic or synthetic), which binds at a receptor site. Agonist: Ligand that binds at, and activates, a regulatory receptor to produce a pharmacological response (can be a full or partial response). Antagonist: Ligand that binds at a receptor site but does not produce a response. Binding is generally, but not exclusively, reversible (competitive) and attenuates the effect of an agonist. Inverse agonist: Ligand that binds and activates the receptor, but produces a response opposite to that observed on activation with an agonist. Afï¬nity: The tenacity of ligand binding to a receptor site. Statistically, it is the probability of the ligand binding to a free receptor at any given time. Efï¬cacy: The ability of ligand to produce a response after binding to a receptor. Constitutive activity: Activity at a receptor in the absence of a ligand.
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Thus, the subjectivity of these types of observations can produce a high degree of experimental bias. These common pitfalls can be remedied by designing experiments with the proper controls: Further reading
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hypothalamicâpituitaryâthyroid axis, hypothalamicâ pituitaryâgrowth hormone axis and sympathoadrenal system have also been described. However, since administration of the deï¬cient hormones does not improve the FMS symptoms, these endocrine deï¬ciencies are likely secondary to the general pain condition.
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Pathophysiology in an internal organ can produce: Stone only Sham endo Ï© stone
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Pain is an individual and subjective experience resulting from complex central nervous signal processing of inputs from memory, emotional status and nociceptive transmission. The aim of clinical trials in pain is to measure a difference in either: How does it compare with placebo? How does it compare with other therapies?
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ROUTES, FORMULATIONS AND DRUG COMBINATIONS L.A. Skoglund OPIOIDS AND CODEINE L. Bromley 269
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⢠⢠Heat (radio-frequency ablation): Localised radio waves produce heat, thereby destroying nerves. Since ârewiringâ may occur over the space of several months, it is important (as when other techniques are used) to ensure that appropriate physiotherapy is undertaken in the pain-free period. Cold (cryotherapy): Used to destroy nerves. Initially considered not to be associated with neuritis, but this is now known to occur.
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The pulse duration or width is the length of time each pulse lasts, usually in microseconds (â®s). The common clinically useful range of adjustment is 100â200 â®s. Disposable or rechargeable batteries can be used. Rechargeable batteries are not as long lasting, but are cheaper in the long run. Therefore, they are appropriate if a machine is going to be used long term. Some newer machines are produced with integral rechargeable batteries that can be charged directly from the mains.
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Figure 37.2 The gall bladder meridian represents a referral pattern from a TP in the trapezius muscle. The dark grey shaded areas show the more frequent pain referral pattern of a TP. The light grey shows areas of less frequent pain referral. From Acupuncture â A Scientiï¬c Appraisal by Ernst and White. Reprinted by permission of Elsevier Ltd and Dr Michael Cummings. Electrical stimulation
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Physical examination and laboratory work Personal psychiatric history Assessing opioid responsiveness
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PALLIATIVE CARE Palliative care guidelines National ⢠2000 Royal College of Physicians. Principles of pain control in palliative care for adults. ⢠1998 National Council for Hospice & Specialist Palliative Care Services (NCHSPCS) Guidelines for managing cancer pain in adults. International ⢠World Health Organisation (WHO) 1996 Cancer pain relief: with a guide to opioid availability. Second edition of the WHO guidelines for cancer pain relief covers: pain assessment, opioid and non-opioid analgesics, drugs for neuropathic pain, treatment of side effects, enhancement of pain relief and management of psychological disturbances.
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Efferent neurone Enthesitis Heteromeric Hyperalgesia
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Understanding the mechanisms, pathophysiology and potential sequelae of concussion is important for the proper protection of athletes, whether they be in recreational, collegiate or professional environments. Ongoing research is leading to an enhanced appreciation of this important problem in athletic endeavor and is providing new insights into prevention and treatment. Conventional wisdom considering concussion as a short-term phenomenon characterized by transient functional deficiencies is misleading given the scientific evidence presented in this chapter. Overall on the global level, normally cerebral blood flow (CBF) and metabolic demand for glucose utilization are coupled. However, there are obvious derangements in cerebral blood flow (CBF) as a result of traumatic brain injury. For
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Clearly, past concussion management strategies were based upon subjective information and dependent upon patient report. With return to play guidelines based only on presence and duration of mental status changes and self-reported symptoms, some injured athletesâespecially those with mild injuriesâwere "falling through the cracks" in the concussion management system. Of interest, concussed athletes were subjectively reporting cognitive problems such as memory disturbance, inattention, and slowed thinking in addition to somatic symptoms such as headache and nausea. In the 1980s, researchers such as Alves (1987) and Barth (1989) began exploring these symptom complaints in a more objective manner. Since the 1980s neuropsychological testing has been a valuable tool in concussion research and practice. At first, neuropsychological testing was used in sports concussion for research purposes. From over two decades of research, important findings have consistently emerged, which has led to the clinical use of neuropsychological testing to manage the injury. Professional sports organizations were some of the first to recognize and put into practice a neuropsychological testing program, which typically included baseline cognitive assessments and follow-up testing of concussed athletes. In 1994, the National Football League (NFL) established a committee on mild traumatic brain injuries in response to concerns about repetitive sports concussions. The committee included team physicians, athletic trainers, and equipment managers from the NFL, as well as a variety of experts in brain injury, basic science, and epidemiology. In 1996, the NFL began to record details of each concussion and chart the recovery process. This research has laid the foundation for a series of papers on concussion in professional football, published in Neurosurgery on a regular basis. In 1998, the commissioner of the NFL supported baseline neuropsychological testing and data-based concussion management programs throughout the league. Although each NFL club is an individual organization, most have decided to adopt a concussion management program that includes baseline and post-injury neuropsychological testing. At present, many clubs are beginning to transition from paper and pencil based testing to computerized testing. Another professional sports organization that has led the way in concussion management is the National Hockey League. This organization became increasingly concerned about understanding concussion and its short and long term effects in ice hockey athletes. In the mid 1990s, Gary
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0.8 0.7-r Several studies have examined practice effects on Trails A and B in nonathlete populations (Basso et al., 1999; Bornstein et al., 1987; Craddick and Stern, 1963; desRosiers and Kavanagh, 1987; Dikmen et al., 1999; Dikmen et al., 1983; Dye, 1979; Matarazzo et al., 1974; Mitrushina and Satz, 1991). However, most of these studies have examined practice effects at only one retest interval (Basso et al., 1999; Bornstein et al., 1987; desRosiers and Kavanagh, 1987; Dikmen et al., 1999; Matarazzo et al., 1974). Two studies on non-athletes have examined practice effects at two or more retest intervals (Craddick and Stern, 1963; Mitrushina and Satz, 1991). Results from both studies revealed statistically significant practice effects on Trails A. On Trails B Mitrushina and Satz (1991) compared mean differences between time points and found statistically significant practice effects at two, one-year intervals. Craddick and Stern (1963) used the same approach and found statistically significant practice effects on Trails B after a third one-month interval. In the studies using only one retest interval, significant practice effects were found on both Trails A and B (desRosiers and Kavanagh, 1987; Dye, 1979). In contrast, Dikmen and colleagues (Dikmen et al., 1999) used the effect size method and Basso and colleagues (1999) used the RCI practice method and found no evidence of significant change on either Trailmaking test. Practice effects on Trails A and B have also been examined in athletes. In a study conducted by Macciocchi and colleagues (2001), MANOVA was used to examine differences among 24 concussed athletes on Trails A and B, the SDMT, and several other neuropsychological tests. Athletes were tested at 24 hours, five days, and ten days post-injury following a first concussion. These investigators found that even these concussed athletes showed significant improvement from pre-season baseline scores to five days postinjury on Trails A, however, they did not show significant improvement at 24 hours post-injury. On Trails B, these athletes showed a large improvement in performance from baseline to 24 hours post-injury that persisted to five days post-injury. For both Trails A and B, there was no further improvement in performance from five to 10 days post-injury. Macciocchi and colleagues (1996) reported on practice effects for Trails A and B in 183 athletes with one concussion and matched non-injured, nonathlete student controls. Practice effects were reported for both athletes and controls at 24 hours, five days, and ten days post-injury. Conventional statistical analyses were used to compare mean differences between injured athletes and controls. These investigators found that both injured athletes
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Neuropsychological Assessment
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168 MR Spectroscopy and Concussion
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Alpha activity can be seen in about three-fourths of all individuals when they are awake and relaxed. Asking these individuals to relax and close their eyes will result in recurring periods of several seconds in which the EEG consists of relatively large, rhythmic waves of about 8-12 Hz. This is the alpha rhythm, the presence of which has been related to relaxation and the lack of active cognitive processes. If someone who displays alpha activity is asked to perform cognitive activity such as solving an arithmetic problem in their head, alpha activity will no longer be present in the EEG. This is referred to as alpha blocking. Typically, with cognitive activity the alpha rhythm is replaced by high frequency low amplitude EEG activity referred to as beta activity. Since Berger's first discovered the alpha rhythm, a variety of studies have focused on its relationship to psychological processes and the broad developments of the cognitive and affective neurosciences amplified this interest (see Shaw, 2003 for a review). Based on factor analysis of alpha activity some have suggested that alpha activity be divided into two or three separate frequency bands (Klimesch, 1999). Beta activity occurs when one is alert. Traditionally, lower-voltage variations ranging from about 18 to 30 Hz have been referred to as beta and higher frequency lower-voltage variations ranging from about 30 to 70 Hz or higher as gamma. Initial work suggested that gamma activity is related to the brain's ability to integrate a variety of stimuli into a coherent whole. For example, Catherine Tallon-Baudry and her colleagues (Tallon-Baudry, Bertrand, Delpuech, & Pemier, 1997) showed individuals pictures of a hidden Dalmatian
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Berger, H. (1929). Uber das Elektrenkephalogramm des Menschen. Translated and reprinted in Pierre Gloor, Hans Berger on the electroencephalogram of man. Electroencephalography and clinical neurophysiology (Supp. 28) 1969, Amsterdam:Elsevier. Adrian, E., & Matthews, B. (1934). Berger rhythm: Potential changes from the occipital loves of man. Brain, 57, 355-385. Li. C , & Jasper, H. (1953). Microelectrode studies of the electrical activity of the cerebral cortex in the cat. Journal of Physiology, 121, 117-140. Lutzenberger, W., Elbert, T., & Rockstroh, B. (1987). A brief tutorial on the implications of
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Since 1929 when the human EEG was first measured (Berger, 1929) modem science has learned an enormous amount about the current sources of the EEG and the manner in which ensembles of synaptic generators are synchronously organized. It is known that short distance local generators are connected by white matter axons to other local generators that can be many centimeters distant. The interplay and coordination of short distance local generators with the longer distant white matter connections has been mathematically modeled and shown to be essential for our understanding of the genesis of the EEG (Nunez, 1981; 1995; Thatcher and John, 1977; Thatcher et al, 1986). The first qEEG study was by Hans Berger (1929) when he used the Fourier transform to spectrally analyze the EEG because Dr. Berger recognized the importance of quantification and objectivity in the evaluation of the electroencephalogram (EEG). The relevance of quantitative EEG (qEEG) to the diagnosis and prognosis of traumatic brain injury (TBI) stems
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contact sports (Ommaya & Gennarelli, 1974; Meythaler, 2001), DAI is not directly visible on CT scan. MRI is better at revealing these subtle lesions (Fig. 24), although special sequences may be needed (Fig. 25). Stein
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Aerobic Fitness and Concussion
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Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 11.5 software. Participant demographic information was summarized using descriptive data (see Section 2.2.). Aerobic fitness was examined using normative (ACSM, 2000) and descriptive data. Concussion incidence rates were calculated. A series of MANOVAs were used to examine differences in baseline ImPACT module scores and symptoms between the following groups: (a) concussed and non-concussed, (b) high and low estimated V02 max, and (c) concussion history and no concussion history. To examine the relationship of on-field PTA to ImPACT symptoms and neurocognitive impairment, chi-square and odds ratio (OR) analyses "were used to compare the number of reliable cognitive declines (using an 80% CI reliable change estimate [RCE]) presented at 24-72 hours postconcussion in athletes. We used the same RCE formula and 80% CI as suggested by Iverson, Lovell and Collins (2003). Chi-square and OR analyses were also used to compare the likelihood that concussed athletes experienced one or more cognitive declines, and two or more cognitive declines on ImPACT. Chi-square and OR analyses were also used to compare concussion risk among aerobic fitness (high vs. low) and concussion history (concussion history vs. no concussion history) groups. A series of 2 (concussion history) x 2 (aerobic fitness) repeated measures
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416 Zillmer, E., Schneider, J., Tinker & Kaminaris, C.I. (2006). A history of sports-related concussions: A neuropsychological perspective. In: Sports neuropsychology: Assessment and management of of traumatic brain injury, R.J. Echemendia, Editor. New York: Guilford Publications. Bigler, E.D., Orrison, W.W. (2004). Neuroimaging in sports-related brain injury. In: Traumatic brain injury in sports: An international neuropsychological perspective, M. Lovell, Echemendia, R., Barth, J., Collins, M., Editor. Lisse: Psychology Press.
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447 should follow nutritional guidelines and focus on healthy eating behavior rather than on weight issues. I also should say that the most important aspect of coaching is to treat the athletes with respect and dignity regardless of gender, race and social preferences. Coach Kaidanov: / should say that I agree with the notion that gender influences all aspects of coaching including practices, competition, and coaches' interaction with athletes. Gender influences coaches' interpretation of athletes' responses to work load, their expectations and effects of psychological pressure. It is important to note that gender is an important individual characteristic. Accordingly, if you would like to follow the principle of individualization, you should directly tie this to gender. To my knowledge, there is not much research and recommendations how to deal with gender issues in coaching practice. Q8. Among athletes it is common to hide fear in order to avoid appearing weak. However, it is known that in previously injured athletes, fear of subsequent injuries may induce erratic emotional responses, avoidance reactions, and bracing behaviors. In your opinion, and in terms of psychological recovery, do you think that athletes recover better, or faster, from an injury if the injury is given more attention, or less attention? Also, do you feel that there is a difference in response to attention paid to the injury in male vs. female athletes? Coach Ganter: I would have to say more attention is needed when you coach injured athletes. I can not picture an injury getting less attention, there is no motivation there. I would have to say more attention would help promote the quicker recovery. I think the better rehabilitation and more attention an athlete receives would get them back quicker. I have no opinion regarding the gender differences. Coach Jepson: / think that fear is important protective mechanism and plays an important role in athletics. As I said, gymnastics is an extremely risky sport and not surprisingly, fear is present every time a gymnast preparing for or performing a routine. Most importantly, however, to dissociate fear per se, from ability to control fear. Successful gymnasts, regardless of gender can control fear, trust their body and their coaches. I also believe that fear coming from uncertainty due to lack of consistency in performing the routines. Thus, the more consistent and the reliable skill, the less fear that is present. Unlike other less risky sports, we should think of the fear in terms offear of being hurt, versus the fear of being embarrassed, or the fear of failure.
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management skill are just a few attributes of the injury free training environment. There is a large preparation period prior to competition. You have to build proper confidence with proper progression of physical skills and general fitness. Slowly, brick by brick build various aspects of an athlete' s progression, with no rush. You must build fundamentals, and certainly discipline and commitment. Coach Battista: First, knock off the old school macho stuff and be more concerned about safetly factoring in water breaks, taking into account environmental conditions (heat and humidity, lightning, air quality). Educate them about the value of mental training and help them buy into relaxation and feedback as a skill no different than skating or shooting. To be resourceful by utilizing school supplied or community volunteer experts that can help with nutrition, psychology, strength and condition (making sure you do background checks and follow-ups on suspicious behavior ex. a volunteer strength trainer recommending supplements without your knowledge. Teaching the kids the value of proper warm-up and flexibility (not just stretching) is an essential issue. Urging the kids to play within the rules and to not ''cheat" by hitting away from the play or pushing the rules to extremes which may incite retaliations (in the more physical sports and the stick yielding sports especially) is another fundamental rule. Educating parents about the new research and findings is crucial also. Numerous times we have had parents argue with us when we held their son out of competition due to concussion and in their minds the kid needs to just ''suck it up and tough it out." Parents should understand the coaches and the team's policies in advance. Coach Rose: / think my advice would be to monitor the amount of jumping used in training and instruction because I think many injuries occur because of lack of sufficient strength to handle the training level. When athletes tire, they become more susceptible to injury, and the coach needs to pull back their demands as opposed to pushing the players harder. There is no question that proper instruction in the performance of the necessary skills correlates with a safer environment, and coaches are responsible for making sure the training facility is safe and properly maintained. In closing, it is critical for the coaches to work with the health professionals in assuming that their athletes are ready to restart their participation and not listen only to the athlete. Coach Kaidanov: / would say that the most important thing in coaching is to be patient. Encourage challenge when only an athlete is ready to meet this challenge. Do not expect quick success but build fundamental skill, conditioning and character.
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These icons are used on the e-Learning Connection page and the Online Learning Center to denote types of content.
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The plasma membrane that surrounds and keeps the cell intact regulates what enters and exits a cell. The plasma membrane is a phospholipid bilayer that is said to be semipermeable because it allows certain molecules but not others to enter the cell. Proteins present in the plasma membrane play important roles in allowing substances to enter the cell. The nucleus is a large, centrally located structure that can often be seen with a light microscope. The nucleus contains the chromosomes and is the control center of the cell. It controls the metabolic functioning and structural characteristics of the cell. The nucleolus is a region inside the nucleus. The cytoplasm is the portion of the cell between the nucleus and the plasma membrane. The matrix of the cytoplasm is a semiï¬uid medium that contains water and various types of molecules suspended or dissolved in the medium. The presence of proteins accounts for the semiï¬uid nature of the matrix. The cytoplasm contains various organelles. Organelles are small membranous structures that can usually only be seen with an electron microscope. Each type of organelle has a speciï¬c function. One type of organelle transports substances, for example, and another type produces ATP for the cell. Since organelles are composed of membrane, it can be seen that membrane compartmentalizes, keeping the various cellular activities separated from one another (Table 3.1 and Fig. 3.3). Cells also have a cytoskeleton, a network of interconnected ï¬laments and microtubules that occur in the cytoplasm. The name cytoskeleton is convenient in that it allows us to compare the cytoskeleton to the bones and muscles of an animal. Bones and muscle give an animal structure and produce movement. Similarly, the elements of the cytoskeleton maintain cell shape and allow the cell and its contents to move. Some cells move by using cilia and ï¬agella, which are also made up of microtubules. Storage and transport of substances Intracellular digestion
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2 llen B. knew there was something different about the way she stood and walked. She leaned to one side, and her knees didnât line up properly because she had scoliosis, a sideways curvature of the spine that throws the body out of line. So, at 17, while most kids dwelt on high-school graduation, Ellen checked into the hospital. During surgery, doctors carefully hooked steel rods to vertebrae at the top and bottom of Ellenâs spine, fusing the bones together with fragments taken from her hip. The fusions healed in a straightened position. With her spine corrected, Ellen found herself two inches taller, virtually free of back pain, and physically similar to the other students in her class. In addition to being able to proceed with graduation plans, she now could go shopping for clothes without the concern that they wouldnât âhangâ correctly. After the operation, Ellen knew that the skeleton ordinarily permits ï¬exible body movement without any pain. It serves as an attachment for muscles, whose contraction makes the bones move so that we can walk, play tennis, type papers, and do all manner of activities. The bones also support and protect. For example, the large heavy bones of the legs support the entire body against the pull of gravity; the skull protects our brain; and the rib cage protects the heart and lungs. Bones have other functions too: they are the site of blood cell formation, and they store mineral salts. This chapter reviews the structure and function of bones, which are organs in the skeletal system.
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a. Exercise can help prevent osteoporosis, but when playing golf, you should carry your own clubs and walk instead of using a golf cart. b. Normal bone growth compared to bone from a person with osteoporosis. III. Movement and Support in Humans
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pressure compresses the arteries that serve the nerve ï¬bers of the retina, where photoreceptors are located. The nerve ï¬bers begin to die due to lack of nutrients, and the person becomes partially blind. Eventually, total blindness can result. The third layer of the eye, the retina, is located in the posterior compartment, which is ï¬lled with a clear gelatinous material called the vitreous humor. The retina contains photoreceptors called rod cells and cone cells. The rods are very sensitive to light, but they do not see color; therefore, at night or in a darkened room we see only shades of gray. The cones, which require bright light, are sensitive to different wavelengths of light, and therefore we have the ability to distinguish colors. The retina has a very special region called the fovea centralis where cone cells are densely packed. Light is normally focused on the fovea when we look directly at an object. This is helpful because vision is most acute in the fovea centralis. Sensory ï¬bers from the retina form the optic nerve, which takes nerve impulses to the brain. The ear has two sensory functions: hearing and balance (equilibrium). The sensory receptors for both of these are located in the inner ear, and each consists of hair cells with stereocilia (long microvilli) that are sensitive to mechanical stimulation. They are mechanoreceptors.
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The female reproductive system includes the organs depicted in Figure 16.5 and listed in Table 16.2. The female gonads are paired ovaries that lie in shallow depressions, one on each side of the upper pelvic cavity. Oogenesis is the production of an egg, the female gonad. The ovaries alternate in producing one egg a month. Ovulation is the process by which an egg bursts from an ovary and usually enters an oviduct.
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As a follicle matures, the oocyte enlarges and is surrounded by layers of follicular cells and ï¬uid. Eventually, ovulation occurs, the mature follicle ruptures, and the secondary oocyte is released. A single follicle actually goes through all stages in one place within the ovary. The hypothalamus produces GnRH (gonadotropin-releasing hormone). GnRH stimulates the anterior pituitary to produce FSH (follicle-stimulating hormone) and LH (luteinizing hormone). FSH stimulates the follicle to produce estrogen, and LH stimulates the corpus luteum to produce progesterone. Estrogen and progesterone maintain the sexual organs (e.g., uterus) and the secondary sex characteristics, and exert feedback control over the hypothalamus and the anterior pituitary.
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igure S.1 shows HIV (human immunodeï¬ciency virus) budding from a T lymphocyte, its primary host. No wonder the immune system falters in a person with an HIV infection. The very cells that orchestrate the immune response are under viral attack. While we in the United States bear a tremendous expense to treat people infected with HIV, this luxury is not available to the many more that are infected in the developing countries. Will there be a vaccine sometime soon? If so, the immune system would be primed to control the infection before it establishes itself. There might be something about the virusâits mode of transmission or the course of the diseaseâthat will make any vaccine ineffective. Then, too, a vaccine for one type of HIV infection may not be effective against another type. HIV is a family of viruses, and each type has different subtypes. Both HIV-1 and HIV-2 infections are found in Africa, while only HIV-1 is prevalent in the United States and most other countries of the world. There are several subtypes of HIV-1, and among these, HIV-1C is extremely virulent and is now wreaking havoc in sub-Saharan Africa. It may hit the United States sometime soon. The burden of avoiding an HIV infection is on the individual. We all must come to realize the importance of our T lymphocytes and take measures to protect them from possible destruction by all types of HIV. The various ways to prevent infection discussed on page 362 should be followed faithfully by all. An HIV infection usually leads to AIDS (acquired immunodeï¬ciency syndrome). The full name of AIDS can
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Recall that carriers are individuals who appear normal but can pass on an allele for a genetic disorder. Note here that the second genotype is a carrier female because although a female with this genotype appears normal, she is capable of passing on an allele for color blindness. Color-blind females are rare because they must receive the allele from both parents; color-blind males are more common since they need only one recessive allele to be color blind. The allele for color blindness has to be inherited from their mother because it is
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1. Should people be encouraged or even required to have their genes analyzed so that they can develop programs to possibly prevent future illness? 2. Should employers be encouraged or required to provide an environment suitable to a personâs genetic proï¬le? Or should the individual avoid a work environment that could bring on an illness? 3. How can we balance individual rights with the public health beneï¬t of matching genetic proï¬les to detrimental environments? G S
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The discovery that metabolic disorders run in certain families suggested to early investigators that genes control the the metabolism of a cell. The mental retardation seen in persons with phenylketonuria (PKU) is caused by an inability to convert phenylalanine to tyrosine. The lack of pigment in albinos is caused by an inability to convert tyrosine to melanin. These and other human conditions are caused by the deï¬ciency of particular enzymes. Laboratory experiments performed over many years ï¬nally showed that a gene is a segment of DNA that codes for a protein. If a person inherits a faulty gene, the sequence of bases in DNA is abnormal, and a particular enzyme is not constructed normally. We now know that DNA contains a triplet codeâevery three bases (a triplet) represents (codes for) for one amino acid (Table 21.2). The genetic code is essentially universal. The same codons stand for the same amino acids in most organisms, from bacteria to humans. This illustrates the remarkable biochemical unity of living things and suggests that all living things have a common evolutionary ancestor.
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be reduced by adopting protective behaviors and the right diet. scrape away hide, cut tendons, and easily remove meat from bones. The skulls of early Homos suggest that the portions of the brain associated with speech areas were enlarged. We can speculate that the ability to speak may have led to hunting cooperatively. Other members of the group may have remained plant gatherers, and if so, both hunters and gatherers most likely ate together and shared their food. In this way, society and culture could have begun. Culture, which encompasses human behavior and products (such as technology and the arts), is dependent upon the capacity to speak and transmit knowledge. We can further speculate that the advantages of a culture to H. habilis may have hastened the extinction of the australopithecines. H. habilis warrants classiï¬cation as Homo because of brain size, dentition, and tool use. These early Homos may have had the rudiments of a culture.
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The anatomy of the nerves and muscles is referred to frequently throughout this book. The overview presented here is intended to provide a quick reference for the reader. More specific information is included with each topic as needed. Three fairly distinct components make up the nervous system in the human body: the central nervous system, which is somewhat analogous to the main processing unit of a computer; the peripheral nervous system (PNS), which links the CNS to the muscles; and the sympathetic nervous system, which links the CNS to the internal organs (see figure). The CNS has two major parts, the brain and spinal cord, which in turn have several subdivisions, each of which plays a unique role in regulating the functions of the body. The portion of the brain referred to as the cerebrum acts as a master control system and is responsible for initiating all thought and movement. Memory, personality, vision, hearing, touch, and muscle tone all are housed within the cerebrum. Behind the cerebrum is the cerebellum, which coordinates movement and âsmoothesâ muscle activity. The proper functioning of this region of the brain controls balance during walking and the smooth use of your hands and arms. Beneath the cerebrum and cerebellum is the brain stem, which contains the nerves that control eye movements and the vital centers that are involved in functions such as breathing and heart rate. Extending downward from the brain stem is the spinal cord, which functions very much like a large electrical cord that carries messages between the brain centers and all other parts of the body. Although numerous biochemical reactions occur in the brain and spinal cord, their major role is to produce electrical activity that stimulates and regulates various bodily activities. These messages Peripheral Nervous System (PNS)
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Spasticity also may be reduced by diazepam (Valium®), which is most often used for the relief of spasms that occur at night. Its calming effect also helps to induce sleep, but its strong sedative effect limits its use during the daytime. Diazepam must be prescribed with caution because it may become addictive if it is used too frequently. Clonazepam (Klonopin®) is closely related to diazepam. Its main use has been to treat certain types of epilepsy. It produces significant relaxation, and thus may be used as an antispasticity medication. Like diazepam, it sedates and is best used at bedtime. When using diazepam or clonazepam, both the doctor and the person with MS must pay attention to the potential for chemical dependency. When properly used at appropriate doses, this is not a major problem. However, if the dose must be continually increased and the person is using the medication not for spasticity but as a crutch to escape the realities of the world, it should no longer be used. Cyproheptadine (Periactin®) is an antihistamine that has antispasticity properties and may be a good add-on medication at certain times. Its sedating effect limits its use, but doses of 4 mg taken when needed may be helpful. A drug that is commonly used for spasms in the muscles of the back is cyclobenzaprine HCl (Flexeril®). It acts quite specifically on these spasms, but also may relieve limb spasms. It usually works best in combination with one of the other antispasticity medications. Gabapentin (Neurontin®) is a newer medication that has been approved for use in seizures. This medication also has antispasticity properties, and when it is taken in doses of over 1 gm per day often eases problematic spasms. L-dopa (Sinemet®) is a Parkinsonâs disease medication that also decreases spasms, especially the painful spasms that tend to occur at night and may become especially prominent and painful. Many of the drugs available to treat Parkinsonâs symptoms can have similar effects on spasms and in difficult situations may be useful. Any of these medications may become less effective when they are taken for a prolonged period (this is referred to as the develop39 PART II
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PO, sublingually, 1â2 mg at ons et of migraine, then 2 mg q30 min, if necessary, to a max imum of 6 mg/ 24 h or 10 mg/wk ty Inha emp lation, 0.36 mg on an (one inhalatio oral suspension n) at onset of migr ycin, give the ets without aine, repeat in b. With azithrom or 2 h after a meal. Give tabl Herbal and Die 5 min, if necessary, to re a maximum of with aluminum tary Supplem stomach, 1 h befo 6 inhalations/24 h Ergotamine tart oral azithromycin ents give not Do ns. ls. rate atio Adults: PO 2 tabl regard to mea In addition to the râs recommend cids. and ly. ture anta caff rate ufac ing eine accu ets tain Man (Cafergot) con at onset of midrugs described well to measure the oral susgraine, then 1 ed or magnesiumand mix above, many her cine ets be ld s tabl are tablet q30 min used to relieve give regular bal medisuspensions shou lease cin, , if necAll d-re essa omy pain nde ithr ry, and exte up clar /or inï¬ammatio to 6 tablets per of these (eg, com c. With . Give the attack or n. For most frey, marigold, 10 tablets/wk or without food on well before peppermint, prim usage is anecdo pension with Shake the suspensi Rectal suppos rose), such tal and unsupp XL) with food. itory 0.5â1 sup orte tablets (Biaxin d few by pos rucclin sup itory onset of migr ical studies. For plements, ther at tion, and inst dose. aine, repeat in e is some evid a stability in solu h after a meal. measuring the 1 h, if with few adverse necessary, up ence of effectiv ion has limited food or within 1 apeutic effects. to two suppos effects; these are eness ycin, give with The IV formulat to achieve ther itories per attack or rucdescribed belo Chondroitin sulf d. With dirithrom followed carefully tent and continuous infusions. ï¬ve suppositori ufacturerâs inst w. tions must be es/wk ate (CS), a sup Children: PO 0.5 rmit , consult the man inte . Indiss ycin for â drug er aire hrom anim the diff â g plem ionn 1 eryt tablet initially, al cartilage or ent extracted ice for Leg e. For IV administerin Also, instructions then 0.5 tablet q30 manufactured ). treatment of cho ng, diluting, and 408 min, if necessar is the r 30â60 min SECTION 4 ycin treat arthritis, is synthetically and from DRUGS AFFECTING THE ENDOCRINE SYSTEM tions for dissolvi y, to a ly (eg, q6h ove maximum of thre Dihydroergotami IV erythrom . thought to dela used to y or intermittent e tablets ne it is rarely used y the breakdown tilage (by inhibit IM 1 mg at ons fuse continuousl mesylate (DH ease. Otherwise, of joint caring elastase, a et of migraine E 45) , may pro syn teol be repe ovial membranes ytic enzyme fou ated hourly, if d levels necessary, to bloo ), nd in tic to stim apeu ulate synthesis total of 3 mg a (by stimulating maintain ther Nursing Notes: Apply 12. For a diabetic n and of new cartilag rptio Your who reports using dietary and Knowle chondrocytes to dge IV 1 mg, client e herbal To increase abso phenicol: repeated, if nece produce teog lycan), and to pro supplem ls, q6h around f. With chloram ents, ssar analyze y, afterents in relation speciï¬c supplem 1 h; max mote the âshock- collagen and proor 2 h after mea re imu to m befo h dos with 1 e cart 2 mg. Do not ilage (by retainin absorbingâ qua their potential exceed impact on blood (1) Give oral drug testinal (GI) upset occurs, give sugar control. 6 mg/wk. lity of g water). Answer: NPH gastroin
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fects (eg, tachycardia, increased rate of respiration, agitation, tremors, convulsive seizures, sweating, heart block, hypotension, delirium, coma). Management consists of diuresis, acidiï¬cation of urine, or hemodialysis to remove the drug from the body. Bupropion overdose: Symptoms include agitation and other mental status changes, nausea and vomiting, and seizures. General treatment measures include hospitalization, decreasing absorption (eg, giving activated charcoal to conscious clients), and supporting vital functions. If seizures occur, an intravenous benzodiazepine (eg, lorazepam) is the drug of ï¬rst choice. Nefazodone or venlafaxine overdose: Symptoms include increased incidence or severity of adverse effects, with nausea, vomiting, and drowsiness most often reported. Hypotension and excessive sedation may occur with nefazodone, seizures and diastolic hypertension with venlafaxine. There are no speciï¬c antidotes; treatment is symptomatic and supportive. Lithium overdose: Toxic manifestations occur with serum lithium levels above 2.5 mEq/L and include nystagmus, tremors, oliguria, confusion, impaired consciousness, visual or tactile hallucinations, choreiform movements, convulsions, coma, and death. Treatment involves supportive care to maintain vital functions, including correction of ï¬uid and electrolyte imbalances. With severe overdoses, hemodialysis is preferred because it removes lithium from the body. Most AEDs are metabolized in the liver and may accumulate in the presence of liver disease or impaired function. The drugs should be used cautiously. Tiagabine is cleared more slowly in clients with liver impairment. Increased plasma levels of unbound tiagabine, increased elimination half-life, and increased frequency of neurologic adverse effects (eg, ataxia, dizziness, drowsiness, tremor) have been observed in clients with mild and moderate hepatic insufï¬ciency. Doses may need to be reduced or given at less frequent intervals. Topiramate may also be cleared more slowly even though it is eliminated mainly through the kidneys and does not undergo signiï¬cant hepatic metabolism. It should be used with caution in the presence of hepatic impairment. Valproic acid is a hepatotoxic drug and contraindicated for use in hepatic impairment. No dosage adjustment is indicated with levetiracetam, oxcarbazepine, or zonisamide.
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3. What are the advantages and disadvantages of the various drugs used to treat parkinsonism? 4. Why is it desirable to delay the start of levodopa therapy and, once started, reduce dosage as much as possible? 5. What is the rationale for various combinations of antiparkinson drugs? 6. What are the major adverse effects of antiparkinson drugs, and how can they be minimized? SELECTED REFERENCES These drugs can cause cardiovascular collapse, hypotension, and respiratory failure. Although the physician is responsible for drugs he or she administers, the nurse often assists by obtaining and perhaps holding the drug vial while the physician aspirates drug solution into a syringe. Accuracy of administration is essential so that adverse reactions can be avoided or treated appropriately if they do occur. The incidence of adverse reactions increases with the amount and concentration of local anesthetic solution injected. Also, adverse reactions to epinephrine may occur. Most preparations are used in particular conditions or bodily locations. For example, lidocaine viscous is used only as an oral preparation for anesthesia of the mouth and throat. Other preparations are used only on the skin. Therapeutic effects depend on the type of drug and the reason for use. Depending on dose and client condition, these effects are usually evident within 20 to 30 minutes after the drugs are given. Relief is usually obtained within a few minutes. Ask the client if the symptom has been relieved, and if not, assess the situation to determine whether further action is needed.
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CNS depressants are drugs that slow down or âdepressâ brain activity. They include alcohol, antianxiety and sedativehypnotic agents, and opiates. 255
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d. Drugs that decrease effects of amphetamines: (1) Acidifying agents
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Functions stimulated by the PNS are often described as resting, reparative, or vegetative functions. They include digestion, excretion, cardiac deceleration, anabolism, and near vision. Approximately 75% of all parasympathetic nerve ï¬bers are in the vagus nerves. These nerves supply the thoracic and abdominal organs; their branches go to the heart, lungs, esophagus, stomach, small intestine, the proximal half of the colon, the liver, gallbladder, pancreas, and the upper portions of the ureters. Other parasympathetic ï¬bers supply pupillary sphincters and circular muscles of the eye; lacrimal, nasal, submaxillary, and parotid glands; descending colon and rectum; lower portions of the ureters and bladder; and genitalia. Speciï¬c body responses to parasympathetic stimulation include: 1. Dilation of blood vessels in the skin 2. Release of nitrous oxide (NO) (previously called endothelium-derived relaxing factor [EDRF]) from the endothelium of blood vessels, resulting in decreased platelet aggregation, decreased inï¬ammation, relaxation of vascular endothelium, and dilation of blood vessels 3. Decreased heart rate, possibly bradycardia 4. Increased secretion of digestive enzymes and motility of the gastrointestinal tract 5. Constriction of smooth muscle of bronchi 6. Increased secretions from glands in the lungs, stomach, intestines, and skin (sweat glands) 7. Constricted pupils (from contraction of the circular muscle of the iris) and accommodation to near vision (from contraction of the ciliary muscle of the eye) 8. Contraction of smooth muscle in the urinary bladder 9. Contraction of skeletal muscle 10. No apparent effects on blood coagulation, blood sugar, mental activity, or muscle strength These responses are regulated by acetylcholine, a neurotransmitter in the brain, ANS, and neuromuscular junctions. Acetylcholine is formed in cholinergic nerve endings from choline and acetylcoenzyme A; the reaction is catalyzed by
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for taking the drug(s). SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM
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Nursing Diagnoses ⢠Decreased Cardiac Output related to disease- or druginduced thyroid disorders
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1. Modiï¬ed by addition of zinc and formation of large crystals, which are slowly absorbed 2. Hypoglycemic reactions are frequent and likely to occur during sleep.
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6. Prepare a teaching plan for perimenopausal or postmenopausal woman about nonpharmacologic measures to manage menopausal symptoms and prevent osteoporosis. Protein-Calorie Excess Causes 1. Excessive intake, especially of carbohydrates and fats Signs and Symptoms 1. Weight gain 2. Obesity
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VITAMIN C Vitamin C (ascorbic acid)/Essential for collagen formation (collagen is a ï¬brous protein in connective tissue throughout the body, including skin, ligaments, cartilage, bone, and teeth) Required for wound healing and tissue repair, metabolism of iron and folic acid, synthesis of fats and proteins, preservation of blood vessel integrity, and resistance to infection
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Planning/Goals How Can You Avoid This Medication Error?
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1. Decreased serum sodium 2. Decreased plasma volume and cardiac output 3. Decreased blood ï¬ow to kidneys, decreased glomerular ï¬ltration rate, and decreased ability of kidneys to excrete water 4. Overhydration and swelling of brain cells (cerebral edema). Leads to impaired neurologic and muscular functions. 5. GI changes
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Electrolyte and acidâbase imbalances often occur in critically ill clients and are usually treated as in other clients, with close monitoring of serum electrolyte levels and avoiding excessive amounts of replacement products.
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(2) With potassium preparations, observe for hyperkalemia. The client will: ⢠Receive antimicrobial drugs accurately when given by health care providers or caregivers ⢠Take drugs as prescribed and for the length of time prescribed when self-administered as an outpatient ⢠Experience decreased fever, white blood cell (WBC) count, and other signs and symptoms of infection ⢠Be monitored regularly for therapeutic and adverse drug effects ⢠Receive prompt recognition and treatment of potentially serious adverse effects ⢠Verbalize and practice measures to prevent future infections ⢠Be safeguarded against nosocomial infections by health care providers
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1. How does the body defend itself against infection? 2. When assessing a client, what signs and symptoms may indicate an infectious process? 3. Do all infections require antimicrobial drug therapy? Why or why not? 4. With antimicrobial drug therapy, what is meant by the terms bacteriostatic, bactericidal, antimicrobial spectrum of activity, and minimum inhibitory concentration? 5. Why is it important to identify the organism causing an infection? 6. Why are infections of the brain, eye, and prostate gland more difï¬cult to treat than infections of the GI, respiratory, and urinary tracts? 7. What factors promote the development of drug-resistant microorganisms, and how can they be prevented or minimized? 8. What are common adverse effects associated with antimicrobial drug therapy? 9. When teaching a client about a prescribed antibiotic, a common instruction is to take all the medicine and not to stop prematurely. Why is this information important? 10. When a dose of an antibiotic is prescribed to prevent postoperative infection, should it be given before, during, or after surgery? Why? 11. What special precautions are needed for clients with renal or hepatic impairment or critical illness?
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Routes and Dosage Ranges Generic/Trade Name Carbapenems Ertapenem (Invanz) Imipenem/cilastatin (Primaxin) Adults Children
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4. Observe for drug interactions a. Drugs that increase effects of penicillins: (1) Gentamicin and other aminoglycosides Synergistic activity against Pseudomonas organisms when given concomitantly with extended-spectrum (antipseudomonal) penicillins Synergistic activity against enterococci that cause subacute bacterial endocarditis, brain abscess, meningitis, or urinary tract infection Synergistic activity against S. aureus when used with nafcillin (2) Probenecid (Benemid) b. Drugs that decrease effects of penicillins: (1) Acidifying agents (ascorbic acid, cranberry juice, orange juice) (2) Erythromycin Most oral penicillins are destroyed by acids, including gastric acid. Amoxicillin and penicillin V are acid stable. Erythromycin inhibits the bactericidal activity of penicillins against most organisms but potentiates activity against resistant strains of S. aureus. These bacteriostatic antibiotics slow multiplication of bacteria and thereby inhibit the penicillins, which act against rapidly multiplying bacteria. Increased renal toxicity Additive renal toxicity especially in older clients, those with renal impairment, those receiving high dosages, and those receiving probenecid Increases blood levels by decreasing renal excretion of the cephalosporins. This may be a desirable interaction to increase blood levels and therapeutic effectiveness or allow smaller doses. Tetracyclines are bacteriostatic and slow the rate of bacterial reproduction. Cephalosporins are bactericidal and are most effective against rapidly multiplying bacteria. Thus, tetracyclines should not be given concurrently with cephalosporins. These drugs decrease absorption of cefditoren (Spectracef). Give the drugs at least 2 hours apart. Decreases renal excretion of penicillins, thus elevates and prolongs penicillin blood levels
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Oral Sulfonamides 1. Discuss characteristics and speciï¬c uses of macrolide antibacterials. 2. Compare and contrast macrolides with other commonly used antibacterial drugs. 3. Apply principles of using macrolides in selected client situations.
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These are the most frequent adverse effects and may be severe enough to require stopping the drug. (continued ) Nucleoside Reverse Transcriptase Inhibitors (NRTIs) Prototype NRTI Zidovudine Well absorbed with oral (AZT, ZVD, Retrovir) administration Metabolized in the liver to an inactive metabolite, which is excreted in urine Often causes severe anemia and granulocytopenia, which may require stopping the drug, giving blood transfusions, or giving ï¬lgrastim or sargramostim to hasten bone marrow recovery May also cause peripheral neuropathy and pancreatitis Abacavir (Ziagen) Well absorbed with oral administration Approximately 50% bound to plasma proteins Metabolized to inactive metabolites that are excreted in urine and feces May cause serious hypersensitivity reactions Used for patients who do not respond to or cannot tolerate zidovudine
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B Antiretroviral Drugs
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The use of systemic antiviral drugs may be difï¬cult in children because several of the available agents have not been tested in this group, are not available in pediatric formulations, and/or do not have pediatric dosages. Amantadine may be given to prevent or treat inï¬uenza A in children 1 year of age or older, and rimantadine is given only for prevention in children. The optimal dose and duration of amantadine or rimantadine therapy have not yet been established. Cidofovir is highly nephrotoxic and should probably not be used in children because of long-term risks of carcinogenicity and reproductive toxicity. Consistent with most other viral infections, few guidelines exist regarding the use of anti-HIV drugs in children. Most HIV infections in children result from perinatal transmission, and HIV testing should be a part of routine perinatal care. HIV-seropositive females should receive zidovudine to prevent perinatal transmission. At 14 to 34 weeks of gestation, zidovudine should be administered at a dose of 100 mg PO 5 times a day until delivery. At delivery, a loading dose of 2 mg/kg should be administered, followed by 1 mg/kg/hour until birth. The infant is then administered zidovudine 2 mg/kg every 6 hours for the ï¬rst 6 weeks of life. If perinatal infection occurs, the infant usually develops symptoms (eg, an opportunistic infection or failure to thrive) within the ï¬rst 3 to 8 months of life. Zidovudine, which is approved for treatment of HIV infection in children, is usually the drug of choice. As in adults, anemia and neutropenia are common adverse effects of zidovudine.
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of glucose into the glucan ï¬brils that compose the walls of most fungi. Depletion of glucan in the fungal cell wall leads to leakage of cellular contents and cell death. Because human cells do not have cell walls or contain beta glucan, these drugs are less toxic than other systemic antifungal drugs. At present, caspofungin is indicated for treatment of invasive aspergillosis in clients who cannot take or do not respond to amphotericin B or itraconazole. It has not been studied for initial treatment of invasive aspergillosis. Caspofungin is given IV and is highly bound to plasma albumin. After a single 1-hour infusion, plasma levels decline in three main phases. A short alpha phase occurs immediately after infusion; an intermediate beta phase has a half-life of 8 to 11 hours; and a longer gamma phase has a half-life of 40 to 50 hours. There is minimal biotransformation or excretion during the ï¬rst 30 hours after infusion, then the drug is metabolized slowly and excreted in feces and urine. Caspofungin is usually well tolerated with doses of 50 mg/day. Adverse effects occur in fewer than 3% of recipients and include nausea, vomiting, and infusion site complications. With doses of 50 to 70 mg daily, adverse effects include fever, headache, nausea, phlebitis or thrombophlebitis at infusion sites, and abnormal laboratory reports (eg, decreased white blood cells, hemoglobin and hematocrit; increased serum potassium and liver aminotransferase enzymes). Dosage must be reduced with moderate hepatic impairment (eg, after a 70-mg loading dose, a 35-mg daily dose is recommended rather than the 50-mg daily recommended for clients with normal liver function). The drug has not been studied in clients with severe hepatic impairment. No dosage adjustment is needed for renal impairment. Cyclosporine increases the effects of caspofungin, including potential liver damage. Concomitant use is not recommended unless potential beneï¬ts outweigh potential risks. Drugs that decrease effects include anti-HIV drugs (eg, efavirenz, nelï¬navir, nevirapine), anticonvulsants (eg, carbamazepine, phenytoin), dexamethasone, and rifampin. Concurrent administration may signiï¬cantly reduce caspofungin blood levels and therapeutic effectiveness unless dosage is increased (eg, from the usual 50 mg to 70 mg daily). Flucytosine is a nucleoside analog that is converted to 5-ï¬uorouracil inside the fungal cell. The 5-ï¬uorouracil is then metabolized to products that interfere with the synthesis of fungal RNA and DNA. Flucytosine has little activity against molds or dimorphic fungi and is mainly used for yeast infections. It has signiï¬cant activity against Candida and Cryptococcus neoformans organisms. Flucytosine is not used alone because drug resistance develops. It is most often used in combination with amphotericin B to treat systemic candidiasis and cryptococcal meningitis. The combination allows smaller doses of amphotericin B and prevents emergence of ï¬ucytosine resistance. If high doses of amphotericin B are used, ï¬ucytosine adds no additional beneï¬t. Flucytosine is well absorbed with oral use and widely distributed into most body ï¬uids, including urine, aqueous humor, bronchial secretions, and CSF. Levels in CSF reach 60% to 80% of serum levels. More than 90% of each dose is excreted Hydroxychloroquine (Plaquenil)
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⢠Assess for exposure to parasites. Although exposure is inï¬uenced by many variables (eg, geographic location, personal hygiene, environmental sanitation), some useful questions may include the following: ⢠Does the person live in an institution, an area of poor sanitation, an underdeveloped country, a tropical region, or an area of overcrowded housing? These conditions predispose to parasitic infestations with lice, scabies, protozoa, and worms. ⢠Are parasitic diseases present in the personâs environment? For example, head lice, scabies, and pinworm infestations often affect school children and their families. ⢠Has the person recently traveled (within the previous 1 to 3 weeks) in malarious regions? If so, were prophylactic measures used appropriately? ⢠With vaginal trichomoniasis, assess in relation to sexual activity. The disease is spread by sexual intercourse, and
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The goal of anthelmintic drug therapy may be complete eradication of the parasite or reduction of the âworm burden.â
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⢠Assess baseline values of laboratory and other diagnostic NURSING ACTIONS m. With sirolimus, give 4 h after a dose of cyclosporine; give consistently with or without food; and do not give with grapefruit juice. With oral sirolimus solution, use the amber oral dose syringe to withdraw a dose from the bottle; empty the dose into a glass or plastic container with at least 60 mL of water or orange juice (do not use any other diluent); stir the mixture vigorously and ask the patient to drink it immediately; reï¬ll the container with at least 120 mL of water or orange juice; stir vigorously and ask the patient to drink all of the ï¬uid. n. Give IV tacrolimus as a continuous infusion by infusion pump. o. Give the ï¬rst dose of oral tacrolimus 8â12 h after stopping the IV infusion. 2. Observe for therapeutic effects a. When a drug is given to suppress the immune response to organ transplants, therapeutic effect is the absence of signs and symptoms indicating rejection of the transplanted tissue. b. When azathioprine or methotrexate is given for rheumatoid arthritis, observe for decreased pain.
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Critically ill clients often have multiple cardiovascular and other disorders that require drug therapy. Acute HF may be the primary critical illness. It may also be precipitated by other illnesses or treatments that alter ï¬uid balance, impair myocardial contractility, or increase the workload of the heart beyond its capacity to accommodate. Management is often symptomatic, with choice of drug and dosage requiring careful titration and frequent monitoring of the clientâs response. Cardiotonic, diuretic, and vasodilator drugs are often required. All of the drugs should be used with caution in critically ill clients.
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Automaticity is the heartâs ability to generate an electrical impulse. Any part of the conduction system can spontaneously start an impulse, but the sinoatrial (SA) node normally has the highest degree of automaticity and therefore the
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Antidysrhythmic drugs are less often needed in children than in adults, and their use has decreased with increased use of catheter ablative techniques. Catheter ablation uses radio waves to destroy dysrhythmia-producing foci in cardiac tissue and reportedly causes fewer adverse effects and complications than long-term antidysrhythmic drug therapy. Antidysrhythmic drug therapy is also less clear-cut in children. The only antidysrhythmic drug that is FDA approved for use in children is digoxin. However, pediatric cardiologists have used various drugs and developed guidelines for their use, especially dosages. As with adults, the drugs should be used only when clearly indicated, and children should be monitored closely because all of the drugs can cause adverse effects, including hypotension and new or worsened dysrhythmias. Supraventricular tachydysrhythmias are the most common sustained dysrhythmias in children. IV adenosine, digoxin, procainamide, or propranolol can be used acutely to terminate supraventricular tachydysrhythmias. IV verapamil, which is often used in adults to terminate supraventricular tachydysrhythmias, is contraindicated in infants and small children. Although it can be used cautiously in older children, some clinicians recommend that IV verapamil be avoided in the pediatric
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Cardiac dysrhythmias are common in older adults, but in general only those causing symptoms of circulatory impairment should be treated with antidysrhythmic drugs. Compared with younger adults, older adults are more likely to experience serious adverse drug effects, including aggravation of existing dysrhythmias, production of new dysrhythmias, hypotension, and heart failure. Cautious use is required, and dosage usually needs to be reduced to compensate for heart disease or impaired drug elimination processes. coronary arteries. Foam cells, which promote growth of atherosclerotic plaque, develop in response to elevated blood cholesterol levels. Initially, white blood cells (monocytes) become attached to the endothelium and move through the endothelial layer into subendothelial spaces, where they ingest lipid and become foam cells. These early lesions progress to ï¬brous plaques containing foam cells covered by smooth muscle cells and connective tissue. Advanced lesions also contain hemorrhages, ulcerations, and scar tissue. Factors contributing to plaque development and growth include endothelial injury, lipid inï¬ltration (ie, cholesterol), recruitment of inflammatory cells (mainly monocytes and T lymphocytes), and smooth muscle cell proliferation. Endothelial injury may
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Answer: Actually, there are two errors in this situation. A nurse can only safely administer medication that she has prepared. In this situation, after the medication has been spread on the paper, the dosage will be unclear. Also, a nurse or a family member should never touch Nitropaste without wearing gloves. Hands should be washed after administration. This potent vasodilator is absorbed through the skin, causing systemic effects such as dizziness and headache.
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*Childrenâs dosages from Drug Facts and Comparisons (2002).
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HCTZ, hydrochlorothiazide. *Note that one trade name product may be available in multiple formulations, with variable amounts of antihypertensive, diuretic, or both components. CLIENT TEACHING GUIDELINES
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How Can You Avoid This Medication Error?
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a. Orthostatic hypotension, dizziness, weakness response may be reduced and edema of the gastrointestinal [GI] tract may limit absorption of oral medications. Thiazides may be useful in managing edema due to renal disorders such as nephrotic syndrome and acute glomerulonephritis. However, their effectiveness decreases as the GFR decreases, and the drugs become ineffective when the GFR is less than 30 mL/minute. The drugs may accumulate and increase adverse effects in clients with impaired renal function. Thus, renal function tests should be performed periodically. If progressive renal impairment becomes evident (eg, a rising serum creatinine or blood urea nitrogen [BUN]), a thiazide usually should be discontinued and metolazone, indapamide, or a loop diuretic may be given. Metolazone and indapamide are thiazide-related diuretics that may be effective in clients with significantly impaired renal function. Loop diuretics are effective in clients with renal impairment. However, in chronic renal failure, they have lower peak concentrations at their site of action, which decreases diuresis. Renal elimination of the drugs is also prolonged. If renal dysfunction becomes more severe during treatment (eg, oliguria, increases in BUN or creatinine) the diuretic may need to be discontinued. If high doses of furosemide are used, a volume-controlled IV infusion at a rate of 4 mg/minute or less may be used. If IV bumetanide is given to clients with chronic renal impairment, a continuous infusion (eg, 12 mg over 12 hours) produces more diuresis than equivalent-dose intermittent injections. Continuous infusion also produces lower serum drug levels and therefore may decrease adverse effects. Potassium-sparing diuretics are contraindicated in clients with renal impairment because of the high risk of hyperkalemia. If they are used at all, frequent monitoring of serum electrolytes, creatinine, and BUN is needed.
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Diuretics are often taken in the home setting. The home care nurse may need to assist clients and caregivers in using the drugs safely and effectively, monitor client responses (eg, assess nutritional status, blood pressure, weight, and use of over-the-counter medications that may aggravate edema or hypertension with each home visit), and provide information as indicated. In some cases, the home care nurse may need to assist the client in obtaining medications or blood tests (eg, serum potassium levels).
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Little information has been reported on racial or ethnic differences for lipid lowering drugs. Members of minority populations (eg, African Americans, Mexican Americans) are less likely to be treated than Caucasians. Despite an increased prevalence of diabetes and obesity, American Indians appear to have lower cholesterol levels than the United States popu-
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Interventions SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM
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Nursing Notes: Apply Your Knowledge
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⢠Risk for Injury related to adverse drug effects ⢠Deï¬cient Knowledge related to nondrug measures to reduce nausea and vomiting and appropriate use of antiemetic drugs
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more likely to occur after prolonged use (eg, 2 years or longer) and after a total dose of at least 1.5 g. Cautious use of MTX is especially indicated in clients with preexisting liver damage or impaired hepatic function. Liver function tests should be closely monitored. ⢠Paclitaxel is mainly metabolized by the liver and may cause more toxicity in clients with impaired hepatic function. ⢠Procarbazine causes more toxic effects in clients with hepatic impairment. Hospitalization is recommended for the ï¬rst course of therapy. ⢠Topotecan is cleared from plasma more slowly in clients with hepatic impairment, but dosage reductions are not recommended. ⢠Vinblastine and vincristine may cause more toxicity with hepatic impairment and dosage should be reduced 50% for clients with a direct serum bilirubin value above 3 mg/dL. Other drugs that should be used with caution because of their hepatic effects include the antineoplastic hormones and hormone antagonists. The antiandrogens include bicalutamide, flutamide, and nilutamide. Bicalutamide has a long serum half-life in clients with severe hepatic impairment. Excretion may be delayed and the drug may accumulate. The drug should be used with caution in clients with moderate to severe hepatic impairment, and liver function tests are needed periodically during long-term therapy. Flutamide is associated with serum aminotransferase abnormalities, cholestatic jaundice, hepatic encephalopathy, hepatic necrosis, and a few deaths. Liver function tests should be performed periodically and at the ï¬rst sign or symptom of liver dysfunction (eg, pruritus, dark urine, jaundice). Flutamide should be discontinued if jaundice develops in clients who do not have liver metastases or if serum aminotransferase levels increase more than 2 to 3 times the upper limit of normal. Liver damage usually subsides if ï¬utamide is discontinued or if dosage is reduced. Nilutamide may cause hepatitis or increases in liver enzymes. Liver enzymes should be checked at baseline and every 3 months. If symptoms of liver injury occur or if aminotransferases increase over 2 to 3 times the upper limits of normal, nilutamide should be discontinued. Medroxyprogesterone should be stopped if any manifestations of impaired liver function develop. Tamoxifen and toremifene are antiestrogens. Tamoxifen is associated with changes in liver enzyme levels and occasionally more severe liver damage, including fatty liver, cholestasis, hepatitis, and hepatic necrosis. Toremifeneâs elimination half-life is prolonged in clients with hepatic cirrhosis or ï¬brosis. e. Drugs that increase effects of vinca alkaloids: (1) Erythromycin increases vinblastine toxicity; itraconazole increases vincristine toxicity
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Answer: Start by assessing what Mrs. Jetson knows about glaucoma and providing basic information about the condition. Review and write down the order for eye drops. Sometimes the small print on the medication container is difï¬cult to read. Ask Mrs. Jetson if she has taken eye drops before. If so, watch her demonstrate this procedure, reinforcing proper technique (tilt head back, pull down lower lid, drop medication into sac, close eyes, occlude tear duct). Good aseptic technique should be stressed (wash hands, keep container clean, do not let dropper touch eye). Also caution Mrs. Jetson to notify her doctor before taking any medications or remedies.
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Increased plasma volume and body water, approximately 50% in a normal pregnancy Brain growth Internal organ development Figure 67â1 The gestational clock showing the classic teratogenic risk assessment. (Adapted from Niebyl, J. [1999]. Drugs and related areas in pregnancy. In J. Sciarra [Ed.], Obstetrics and gynecology. Philadelphia: Lippincott Williams & Wilkins.)
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Neuroscientific Foundations for Rehabilitation 82.
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Biologic Adaptations and Neural Repair
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Regrow axons, dendrites, and synaptic connections. Retrain circuits, networks, and behaviors. These 3Rs evolved from nature, but they are coming within the grasp of the rehabilitation clinicianâs nurture. This section examines potential interventions. The following section offers traumatic SCI as a model for bringing together the range of strategies needed for the repair of a sensorimotor system. 140.
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171. Functional Neuroimaging of Recovery
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Sensorimotor Training
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Neurostimulators and Neuroprostheses 202
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Common Practices Across Disorders
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cm/second 5 10 20 30 45 100 125 meters/minute 3 6 12 18 27 60 76 feet/second 0.16 0.33 0.66 0.98 1.48 3.28 4.10 km/hour 0.18 0.36 0.66 1.08 1.62 3.60 4.50 mph 0.11 0.22 0.45 0.67 1.01 2.24 2.80 261
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Table 8â7. Prevalence of Central Pain 197. 198.
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trained patients with microcomputer games.215 It took 3 years to enroll subjects and 5 years to complete the trial. Patients were evaluated by a variety of tests at a median of 10 days after the stroke and retested at 1, 3, and 6 months. Subgroups of 64 severe and 57 mildly affected patients were also compared. The primary effect of the enhanced intervention, that included about twice the amount of therapy time, was improved arm function at 1 month. At 6 months, the mildly affected, but not the severely impaired subgroup that received enhanced therapy, had significantly improved in the 9-Hole Peg Test and a motor score. Thus, a moderate addition to usual interventions had some benefit in patients with selective upper extremity movement at entry. Perhaps a better defined and more intensively applied set of enhanced interventions and measures with less serious floor and ceiling effects would generate greater efficacy. The individual trials comparing schools of therapy include many methodologic flaws.216,217 For example, the studies entered too few subjects, given the spectrum of impairments and disabilities of stroke patients, to detect real differences if such differences exist. Thus, they are at risk for a type II statistical error. The trials did not clearly address principles for training skills. The therapists concentrated on movement, rather than upon the ADLs that served as the measure of efficacy. The trials did not include outcomes related to how the therapistsâ efforts affected behavioral compensation for the hemiplegia, compared with changes in the performance of the affected limbs. Indeed, indices of independence in ADLs, the primary outcome measure in these trials, may reflect poorly the primary intention of the schools of physiotherapy, which traditionally has been to improve patterns of movement.202
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Rehabilitation of Specific Neurologic Disorders Complication Pressure sore Abnormal renal tests Atelectasis/pneumonia Autonomic dysreflexia Deep vein thrombosis Pulmonary embolus Renal stone Gastrointestinal hemorrhage Cardiac arrest Percentage 21 11 9 7 5 1 0.5 0.4 0.4
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years; half of these elderly persons fall repeatedly.157 Approximately 5% of falls cause a fracture and another 10% result in serious injury. Falls are a strong risk factor for placement in nursing homes.158 For many geriatric patients, the intrinsic and external causes of falls interact (Table 12â3); a drug causes mild delirium, arthritis makes weight bearing on the knees painful, and residual impairments from an old mild hemiparesis combine to make the person stumble over a raised crack on a sidewalk. Risks for a serious injury from falls in disabled elderly persons differ from independent persons. A Finnish study associated single status, low body mass index, impaired visual acuity, use of long-acting benzodiazepines, and impaired gait with injuries in the disabled group compared to insomnia and diminished sensation in the feet from a peripheral neuropathy in the able group.159 Weakness of the iliopsoas was another common finding in disabled subjects. Although tests of postural instability using force plates have become a growth industry for trying to predict who is at risk for a fall, the simplest physical tests are the manual examination of leg muscle strength, balance, and
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19 FIGURE 1.11. Representation of Ionic Bond Formation (e.g., sodium chloride [table salt])
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Macrophages Macrophages are defense cells that have wandered into the connective tissue from the blood. Scavenger cells, they remove dead cells and foreign agents. Certain macrophages may be ï¬xed to a site (ï¬xed macrophages), as found in the liver and spleen. Others are wanderers, attracted to injured areas by chemicals liberated by injured tissue. These are the free macrophages. Microphages Microphages are other types of white blood cells (neutrophils and eosinophils) that are attracted to
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Now, draw a pointed object more ï¬rmly across the skin and observe. The stroke line turns red in about 10 seconds. This is called the red reaction. In a few minutes, swelling (wheal) and diffuse redness (ï¬are) Haversian canal
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External Intercostal Pectoralis minor Subscapularis
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Metatarsals Body Head possible (e.g., the joint between the ï¬rst and second vertebraâthe atlas and the axis, and the rotation of the head of radius over the shaft of the ulna proximally).
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Range of motion depends on the angle and size of the articulating surfaces and the resistance offered by the intervertebral disk. It also depends on the muscles and ligaments around the spine. For proper movement, remembered that, when one group of muscles (agonists) contract in a direction, the muscles that bring about the opposite movement (antagonists) have to relax. Similarly, the ligaments lying in the opposite side of the movement have to stretch. The greatest motion possible in the spine is in the lower lumbar regionâbetween L5 and S1, where the joint surfaces are largest and disks the thickest. Conversely, there is more chance of damage, inï¬ammation (arthritis), and herniation of disks in this region. Cervical region Flexion, 45° Extension, 55° Lateral bending, 40° Rotation, 70° Lumbar region Flexion, 75° Hyperextension, 30° Lateral and medial bending, 35°
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Costoclavicular ligament Sternoclavicular joint capsule and anterior ligament
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B There are many joints in the region of the hand (Figure 3.42) as there is articulation between the various carpal bones. These are gliding joints. A saddle joint is present between the proximal end of the ï¬rst metacarpal and the trapezium that allows all the movements of the thumb. The carpometacarpal joint (between hamate and metacarpal bone) of the little ï¬nger is also a saddle joint. The carpometacarpal joints of the remaining ï¬ngers are plane joints that
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Flexion and extension at the various joints are different. Metacarpophalangeal joints: ï¬exion, 90°; extension, 30â45° Proximal interphalangeal joint: ï¬exion, 100°; extension, 10° Distal interphalangeal joint: ï¬exion, 90°; extension, 10° Adduction and abduction of ï¬ngers: 20° Because the thumb articulates at right angles to the rest of the ï¬ngers the movements of the thumb is different. The carpometacarpal joint (trapeziumthumb metacarpal joint) of the thumb is a saddle joint that is mobile and allows all movements, including circumduction. Metacarpophalangeal joint of thumb: adduction, 50°; ï¬exion, 90°; extension, 20°; abduction, 70°. It is also possible to oppose the thumb. Minimal axial rotation is also possible at this joint.
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4.6. Excitation-Contraction Coupling
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When calcium levels in the blood drop, muscle contraction is affected. The respiratory muscles stop functioning and breathing stops. To combat such an occurrence, the body has a large supply of calcium in the bones that can be mobilized. Also, to maintain blood calcium levels within a narrow range, hormones such as parathormone, calcitonin, and vitamin D regulate the amount of calcium absorbed from the gut, excreted by the kidney, and mobilized from the bone.
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the pectoral girdle, only the deepest layers are described here. For details of the other muscles, see Muscles That Move the Shoulder. Together with the intercostals, the diaphragm (see Figures 4.25, 4.26, and Table 4.7) is an important muscle involved in respiratory movements. It is a sheet of muscle with a central connective tissue section. The diaphragm separates the thoracic cavity from the abdominopelvic cavity, and structures passing from one cavity to the other pierce through the diaphragm. It, therefore, has a circular origin and inserts into the connective tissue sheet in the center, the central tendinous sheet. The diaphragm is a powerful muscle used during inspiration. It is innervated by the phrenic nerve that descends all the way from cervical regions C3âC5.
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Trapezius Infraspinatus Teres major
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Abducts and medially rotates thigh; may assist in ï¬exion of the hip joint Anterior superior iliac spine
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Gastrocnemius Chapter 5âNervous System
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the ï¬uid inside and around the CNS that cushions and protects the brain. The astrocytes, as the name suggests, are starshaped. They are present between the blood capillaries and the brain and spinal cord, monitoring the substances that enter and leave the brain and preventing sudden changes in the environment around the CNS. This is the blood-brain barrier, and the astrocytes are responsible for its creation. The astrocytes also help at the time of tissue injury. In addition, they take up neurotransmitters from the synapses, break them down and release the products, and make them available to neurons to produce more neurotransmitters. The network of astrocytes, located over the entire brain and spinal cord, form a supporting framework for the CNS. The astrocytes are the most abundant of the neuroglial cells. Microglia are small cells similar to the monocytes and macrophages in the blood. They engulf dead cells and cellular remnants in the CNS. Oligodendrocytes are neuroglia with long, slender processes that come in contact with cell bodies and axons in the CNS. The processes form thin sheaths in the region where they contact an axon. This sheath is wound around the axon, serving as insulation. Because the sheath around the axon is made of many layers of the cell membrane, it is composed of 80% lipids and 20% protein. To visualize the sheath, place a pencil on one end of a thin strip of paper and roll the paper around the pencil. The pencil represents the axon, and the paper represents the process of an oligodendrocyte. This Motor cortex (control of voluntary muscles) Motor speech area (Broca's area)
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Calcitonin is a hormone secreted by cells that lie between or outside the follicles. It causes an increase in the deposition of calcium and phosphates in bones by reducing resorption and facilitating deposition (see page â¢â¢). This is accomplished by inhibiting the action of osteoclasts. As a result of the bone-building effect of calcitonin, it is used to treat osteoporosis.
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tal muscle and mobilize free fatty acids, making glucose and fatty acids available to tissue. They increase the metabolic rate, increase the rate and force of the contraction of the heart and, thereby, the blood pressure. They increase the blood ï¬ow to the heart, liver, and skeletal muscles and also dilate the bronchi. They increase the alertness of the individual. In short, they are largely responsible for the ï¬ght-orï¬ight response.
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Vagina responsible for the cyclical changes that occur in the luteal phase of the menstrual cycle and for the slight increase in body temperature at the time of ovulation. Together with estrogen, progesterone is used in varying doses to prevent ovulation (oral contraceptives). Relaxin The ovaries secrete a hormone called relaxin. This hormone is also secreted by the placenta in pregnant women. Relaxin relaxes the pubic symphysis and other pelvic joints and softens and dilates the uterine cervix at the time of pregnancy.
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Platelet phospholipids; Calcium; VIII
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8.19. The Capillary Network 485
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Dynamics of Blood Flow
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To compensate for the gravitational effects, G suits are worn. These are double-walled pressure suits containing water or compressed air that compress the abdomen and legs with a force proportionate to the G force.
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Total body water volume 40 L, 60% body weight 9.1. Major Fluid Compartments of the Body (the values are approximate for a 70 Kg man)
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Epitrochlear node Radial collecting ducts Some studies4,5 have proven the positive effects of complex physical therapy (CPT) in those with lymphedema. CPT, or complex physical drainage (CPD) or complex decongestive physiotherapy (CDP), is a treatment consisting of massage, compression bandaging, an active exercise program, and skin care. The treatment is given for 1 to 2 hours/day for a few weeks, followed by use of support hosiery. It is designed to improve lymphatic drainage and remove stagnant proteins from the tissues. CPT has been found to be effective in patients with lymphedema following cancer surgery in which lymph nodes have been removed. Prior to massaging the affected area, it is important for the therapist to obtain detailed information about the onset; duration; cause; previous treatments, such as physiotherapy, radiotherapy, chemotherapy, surgery, and medications; skin infections; and loss of function. All of these factors can affect treatment protocol. The therapist needs to assess the hardness of the edema, the condition of the skin and nails, and restriction of active and passive movements. Periodic measurements of the circumference of the limb may give an idea of the progress made with the treatment. The therapist should be open to modifying the treatment plan, according to objective and subjective improvements seen in the patient. Alteration of treatment may include changing the direction or sequence of the massage strokes. The massage technique used for lymphedema is called manual lymph drainage.6 The techniques help clear edema by facilitating lymph ï¬ow through the col-
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10.7. Transverse Section of the Trachea and the Esophagus
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Compresses abdomen Respiratory membrane Alveolus Pulmonary circuit PO = 100 2 PCO2= 40 O2 CO2
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The Massage Connection: Anatomy and Physiology
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Coloring Exercise
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In people with kidney failure and on peritoneal dialysis, the dialysis ï¬uid is injected into the peritoneal cavity. It is left there for some time to allow nutrients to become absorbed and toxins to diffuse out from the blood into the cavity. The ï¬uid is then withdrawn. In this procedure, the peritoneum is used as the membrane across which diffusion occurs. Blood cholesterol levels are measured to assess a personâs risk of coronary heart disease. The total blood cholesterol levels (TC), HDL cholesterol levels, and triglyceride (VLDL) levels are measured. The LDL level is calculated from these three values. A TC of less than 200 mg/dL, an HDL higher than 40 mg/dL, and an LDL below 130 mg/dL are considered normal. Deviations from normal increase the risk of heart disease. Blood cholesterol levels may be reduced by aerobic exercise (increases HDL), diet (low-fat diet), and drugs (increases excretion of bile; decreases synthesis of cholesterol by the liver).
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ATP consists of an adenine and ribose molecule and three phosphate groups. During anabolism, one phosphate group is split, and ATP is converted into ADP, phosphate group, and energy. ATP â ADP Ï© P (phosphate group) Ï© energy Part of this energy is used for the anabolic reaction, and the remaining energy is in the form of heat. During catabolism, part of the energy is transferred to ADP to form ATP during the breakdown of complex molecules. The remaining energy is released as heat, which may be used to maintain body temperature. Energy Ï© ADP Ï© P (phosphate group) â ATP In this way, ATP provides a linkage between anabolism and catabolism. Lateral view
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