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By G. Akrabor. Lewis University. 2018.

This forearm trans- fer is usually combined with release or transfer of the pronator teres buy 200mg extra super viagra otc. The flexor carpi ulnaris is attached to tension the wrist at 10° to 30° of exten- sion as a passive wrist position on the operating room table (Case 8 extra super viagra 200 mg free shipping. Ex- treme dorsiflexion should be avoided because it may cause the opposite deformity and difficulty with releasing objects as many of these patients use tenodesis of the wrist in flexion to aid in finger extension for release of ob- jects (Case 8 discount extra super viagra 200mg on line. The wrist is casted at 20° extension for 4 to 6 weeks. After cast removal, nighttime splinting is continued for 6 months. The addition of a daytime function splint to allow for grasp and release is added if wrist ex- tensors are believed to be too weak. Aggressive therapy is begun to retrain gross motor function and regain strength. Wrists with severe deformities require the Green transfer but with addi- tional lengthening of the finger flexors if finger flexor contractures are pres- ent. After the release of the flexor carpi ulnaris, the finger flexors are length- ened using group Z-lengthening or myofascial lengthening. She felt other children noticed the arm and some chil- Cambria was in a regular fourth grade class and was com- dren had called her crippled. The mother was concerned pletely age-appropriately independent in all activities, 8. Upper Extremity 411 except she could not tie her own shoes. On physical ex- of elbow flexion, full supination, 30° of wrist dorsiflexion, amination, her elbow flexion lacked 10° to full extension, thumb in full abduction at the metacarpal carpal joint, supination lacked 20° to full supination, wrist flexion and and mild flexion at the metacarpal and interphalangeal extension was full, and thumb abduction was full. The fingers were in 30° of flexion at the meta- attempted active finger extension, her wrist flexed to 30°. After 4 weeks, she was With the wrist held passively at 30° of dorsiflexion, she removed from the cast and therapy was started three could extend her fingers fully at the proximal interpha- times a week to focus on joint range of motion, with the langeal and distal interphalangeal joints, but lacked 40° only limitation being that there was no passive wrist flex- of extension at the metacarpal phalangeal joints. She was to wear a wrist extension splint she was observed standing, her elbow was flexed 60°, the that held her wrist in 20° to 30° of extension full time, forearm was pronated, the wrist flexed, the thumb was except during bathing, for 6 more weeks to protect the adducted, and the fingers were midpoint between flexion transferred tendon. After 6 weeks, the splint was removed and extension. She had a myofascial lengthening of the except for nighttime wear, which was to be used for 6 biceps at the elbow, distal release of the pronator teres, months. Functional activities in therapy focused on ac- and a transfer around the ulnar border of the flexor carpi tivities of daily living, and teaching her how to tie her ulnaris to the extensor carpi radialis brevis. After 1 year, Cam- stance myotomy of the adductor pollicis was performed bria and her mother were again evaluated and she was in the palm. Thumb abduction was augmented with a very happy with the outcome because she felt her arm transfer of the palmaris longus. Her mother, however, was un- procedure the hand remains in the ideal positon with 20° happy because she said Cambria, in spite of the surgery of wrist dorsiflexion (Figure C8. The fingers are in a and extensive therapy, still did not use her hand any more postion of comfort and the thumb rests in mild abduction than before. She notes that although she had learned to (Figure C8. She was placed in a long arm cast in 80° tie her shoes, she only used one hand. She was also having some difficulty getting her transferred flexor carpi ulnaris was performed on the arm into shirt sleeves, especially if the sleeves were a lit- dorsolateral side of the wrist. The transfered tendon had become prominent wrist flexion stretching exercises immediately, and by the (Figure C8. She had graduated from high school and time she went to college, the rest wrist position was at 30° wanted to have something done before she started college to 40° extension, and maximum passive wrist flexion in 2 months. On physical examination she had 50° of was to 10° wrist flexion. On follow-up 1 year later, there dorsiflexion at rest and with maximum active wrist flex- was no significant change from the 3-month postopera- ion, could only get to −30° of wrist flexion. On passive tive visit and she was happy with the result. If finger flexors or flexor carpi radialis are lengthened, the flexor carpi ulnaris is transferred into the extensor carpi radialis brevis if there is minimal residual ulnar deviation. Transfer of the flexor carpi ul- naris to the extensor carpi radialis longus allows for wrist extension in a more radial direction.

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The main clinical conditions associ- osteoporosis is one result of these declines generic 200 mg extra super viagra overnight delivery. With age cheap 200 mg extra super viagra amex, ated with the endocrine system involve the pancreas and there is also a decrease in growth hormone levels and di- the thyroid generic 200 mg extra super viagra with amex. Many elderly people develop adult-onset diabetes Thus far, the only commonly applied treatment for en- mellitus as a result of decreased secretion of insulin, docrine failure associated with age has been sex hormone which is made worse by poor diet, inactivity, and in- replacement therapy for women at menopause. Some elderly people also show the ef- plementation has shown some beneficial effects on mu- fects of decreased thyroid hormone secretion. Word Anatomy Medical terms are built from standardized word parts (prefixes, roots, and suffixes). Learning the meanings of these parts can help you remember words and interpret unfamiliar terms. WORD PART MEANING EXAMPLE The Endocrine Glands and Their Hormones trop/o acting on, influencing Somatotropin stimulates growth in most body tissues. Other Hormone-Producing Tissues –poiesis making, forming Erythropoietin is a hormone from the kidneys that stimulates production of red blood cells. Widespread effects on growth, metabolism, reproduc- II. Amino acid compounds—proteins and related compounds (1) Releasing hormones (RH) sent through portal C. Lipids; derived from cholesterol (2) Inhibiting hormones for GH and PRL THE ENDOCRINE SYSTEM: GLANDS AND HORMONES 259 b. Testes—secrete testosterone (1) Stores hormones made by hypothalamus 2. Ovaries—secrete estrogen and progesterone (2) Released by nervous stimulation G. Thymus gland—secretes thymosin, which aids in develop- 2. Controlled by environmental light tex of adrenal gland d. Stomach and small intestine—secrete hormones that regu- e. Follicle-stimulating hormone (FSH)—acts on gonads late digestion f. Kidneys—secrete erythropoietin, which increases produc- 3. Brain—releasing and inhibiting hormones, ADH, oxytocin tion of water in the kidneys 1. Atria of heart—ANP causes loss of sodium by kidney b. Oxytocin—stimulates uterine contractions and lowers blood pressure 4. Pituitary tumors—may cause underactivity or overactiv- 2. Placenta—secretes hormones that maintain pregnancy ity of pituitary and prepare breasts for lactation B. Thyroid gland (1) Prostaglandins—other cells throughout body 1. Hormones produce prostaglandins, which have varied a. Thyroxine (T4) and triiodothyronine (T3) increase effects 12 metabolic rate b. Growth hormone—treatment of deficiency in children, in a. Goiter—enlarged thyroid elderly for bone strength and body mass b. Insulin—treatment of diabetes mellitus (cretinism) or myxedema C. Steroids—reduction of inflammation, suppression of c.

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Studies (85 extra super viagra 200 mg otc,86) have shown that ventral stimulation leads to resolution of dyskinesias and rigidity with concurrent worsening of akinesia order 200 mg extra super viagra, while stimulation of the most dorsal contacts leads to opposite clinical effects buy extra super viagra 200mg amex. Furthermore, both human and primate studies have shown that the discharge rate of the parkinsonian internal pallidal neurons is sustained at a high rate (80 Hz) (45,87). The internal pallidal output via the ansa lenticularis and lenticular fasciculus terminates in the ventral anterior and lateral thalamic nuclei (88) and uses the inhibitory neurotransmitter g- aminobutyric acid. On the basis of these observations, it is hypothesized that medial pallidotomy would be most effective if the lesion were large enough to include the sensorimotor arm and leg areas and include the neurons that give rise to the ansa lenticularis and lenticular fasciculus (Fig. Such a lesion would interrupt the overactive inhibitory ‘‘noisy’’ outflow of clinically relevant sensorimotor regions of the internal pallidum, thereby disinhibiting the motor thalamus (12). Direct evidence for this is still lacking, but in a retrospective analysis it was documented that lesions were more effective when located within the internal pallidum, and the efficacy was reduced when the lesion encroached on the external pallidum (61). Although now it is generally accepted that the lesion should be in the posterior and ventral pallidum, whether lateral pallidum should be included in the lesion is still controversial. This is likely to remain so until a large data set of clinicopathological cases is gathered worldwide. There has been recent quantitative evidence supporting the rationale for use of microelectrode recording in guiding lesion placement in pallidotomy. In only 45% of the patients did the electrophysiological and anatomical targets overlap. Similar posterior and lateral misregistration of the actual target from the electrophysiological target has been described by Tsao et al. These findings imply that surgery based solely on anatomical landmarks may miss the physiological target, even when the lesion is in the correct nucleus. There remain concerns that the increased number of needle tracts necessary for intraoperative microelectrode recordings increase the overall length of the procedure without clear added benefit and also may increase the overall risk of surgical morbidity from hemorrhage or by increasing the overall lesion volume (the summation of multiple microlesions). FIGURE 3 Drawing of the coronal and horizontal sections through the human basal ganglia showing the output pathways from the pallidum. Put ¼ putamen, GPe ¼ external pallidum, GPi ¼ internal pallidum, H, H1, H2 ¼ fields of Forel, IC ¼ internal capsule, ZI ¼ zona incerta. Conversely, there are no studies demonstrating additional morbidity from intraoperative recordings, and so the choice of method of target identification is still largely determined by individual preferences, available equipment, and local expertise. Another group has specifically targeted only the most ventral region of the posterior pallidum and attempted to produce pallidotomy and ansotomy (62). They have performed 31 pallidotomy/ansotomy operations just 0. In this series, they described a 63% reduction in ‘‘off’’ parkinsonism and the cessation of contralateral dyskinesia in 21 of 23 patients who had disabling dyskinesias preoperatively. These reports, however, require further validation before general acceptance. It is clear from these variable lesion locations that the optimal target for unilateral pallidotomy remains a matter of controversy and that neither the ventroposterolateral pallidotomy of Laitinen (73), nor pallidoansotomy of Iacono (62), nor the more extensive internal pallidotomy (46,69,74) can fully explain the clinical findings of alleviation in parkinsonism and levodopa- induced dyskinesia concurrently. BILATERAL PALLIDOTOMY Laitinen (73) and Iacono et al. There are, however, concerns regarding permanent cognitive and bulbar side effects of bilateral pallidotomy, which have been confirmed in a study of 4 patients in whom contemparous bilateral pallidotomy was performed (91). Despite a 40% improvement in motor UPDRS scores and resolution of dyskinesias, one patient developed dysarthria, dysphagia, and eyelid opening apraxia, another developed abulia, and a third developed mental automatisms. An open-label trial of bilateral simultaneous pallidotomy compared with unilateral pallidotomy plus DBS had to be halted early as all three patients with bilateral lesions developed deterioration in speech, swallowing, salivation, depression, apathy, freezing, and falling (92). In another recent series, staged bilateral pallidotomy was associated with a deficit in speech in four patients, one patient had a decline in memory, and there were three cases of infarction Copyright 2003 by Marcel Dekker, Inc. Further, a reduced response to levodopa has been documented in a small number of patients undergoing bilateral staged pallidotomy (93). These results are in contrast to the milder side effects reported in one series of 14 patients who underwent staged bilateral pallidotomy, in whom no overall effect on speech and cognitive function was detected 6 months postoperatively, but in whom five had mild hypophonia, two had transient confusion, two had deterioration of gait, and one had deterioration of a preexisting dysarthria postoperatively (94). A series of 53 bilaterally operated patients was presented with a follow-up of 17 patients for 12 months (95). Major deterioration in speech (defined as a 2 point decline on the UPDRS subset score) occurred in 8% of bilaterally operated patients compared with 4% of unilaterally operated patients, although the study was not specifically designed to compare the two procedures. Similarly, postoperative major deterioration in salivation occurred in 13% and 10% of bilaterally and unilaterally operated patients, respectively.

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This nerve was formerly called the auditory or sensory buy discount extra super viagra 200 mg line, motor buy 200mg extra super viagra mastercard, or mixed generic extra super viagra 200mg otc. The glossopharyngeal (glos-o-fah-RIN-je-al) nerve con- tains general sensory fibers from the back of the tongue and the pharynx (throat). This nerve also contains sensory Disorders Involving the Cranial fibers for taste from the posterior third of the tongue, se- Nerves cretory fibers that supply the largest salivary gland (parotid), and motor nerve fibers to control the swallow- Destruction of optic nerve (II) fibers may result from in- ing muscles in the pharynx. Certain medications, when used in high doses over long periods, can damage the branch of the vestibu- The nervous system is one of the first systems to develop locochlear nerve responsible for hearing. By the beginning of the third week of de- Injury to a nerve that contains motor fibers causes velopment, the rudiments of the central nervous system paralysis of the muscles supplied by these fibers. Beginning with maturity, the nervous sys- lomotor nerve (III) may be damaged by certain infections tem begins to undergo changes. The brain begins to de- or various poisonous substances. Because this nerve sup- crease in size and weight due to a loss of cells, especially in plies so many muscles connected with the eye, including the cerebral cortex, accompanied by decreases in synapses the levator, which raises the eyelid, injury to it causes a and neurotransmitters. The speed of processing informa- paralysis that usually interferes with eye function. Memory di- Bell palsy is a facial paralysis caused by damage to the minishes, especially for recent events. Changes in the vas- facial nerve (VII), usually on one side of the face. This in- cular system throughout the body with a narrowing of the jury results in distortion of the face because of one-sided arteries (atherosclerosis) reduce blood flow to the brain. Degeneration of vessels increases the likelihood of stroke. Neuralgia (nu-RAL-je-ah) in general means “nerve Much individual variation is possible, however, with pain. Although age nerve is known as trigeminal neuralgia or tic douloureux might make it harder to acquire new skills, tests have (tik du-lu-RU). At first, the pain comes at relatively long shown that practice enhances skill retention. As with intervals, but as time goes on, intervals usually shorten other body systems, the nervous system has vast reserves, 10 while durations lengthen. Treatments include micro- and most elderly people are able to cope with life’s surgery and high-frequency current. Word Anatomy Medical terms are built from standardized word parts (prefixes, roots, and suffixes). Learning the meanings of these parts can help you remember words and interpret unfamiliar terms. WORD PART MEANING EXAMPLE The Brain and its Protective Structures cerebr/o brain Cerebrospinal fluid circulates around the brain and spinal cord. Imaging the Brain tom/o cut Tomography is a method for viewing sections as if cut through the body. Disorders of the Brain and Associated Structures cephal/o head Hydrocephalus is the accumulation of fluid within the brain. Cranial Nerves gloss/o tongue The hypoglossal nerve controls muscles of the tongue. Main parts—cerebrum, diencephalon, brain stem, cerebel- balance, muscle tone lum VII. Imaging—computed tomography (CT), magnetic resonance spinal cord imaging (MRI), positron emission tomography (PET) A. Dura mater—tough outermost layer waves produced as brain functions 2. Circulates around and within brain and spinal cord A. Choroid plexus—vascular network in ventricle that C. Cerebral palsy—cause is brain damage before or during A. Lobes—frontal, parietal, temporal, occipital, insula birth B. Injury scious thought, judgment, voluntary actions 1.

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A small percentage of ingested ethanol (0-5%) enters the gastric mucosal cells of the upper GI tract (tongue buy discount extra super viagra 200 mg on line, mouth discount 200 mg extra super viagra overnight delivery, 460 SECTION FOUR / FUEL OXIDATION AND THE GENERATION OF ATP esophagus generic extra super viagra 200 mg with mastercard, and stomach), where it is metabolized. CH3CH2OH Of this, 85 to 98% is metabolized in the liver, and only 2 to 10% is excreted through Ethanol the lungs or kidneys. NAD+ The major route of ethanol metabolism in the liver is through liver alcohol dehy- ADH drogenase, a cytosolic enzyme that oxidizes ethanol to acetaldehyde with reduction NADH + H+ of NAD to NADH (Fig. If it is not removed by metabolism, acetaldehyde exerts toxic actions in the liver and can enter the blood and exert toxic effects in O CH C other tissues. The major enzyme involved is a low Km mitochondrial acetalde- NAD+ hyde dehydrogenase (ALDH), which oxidizes acetaldehyde to acetate with generation ALDH of NADH (see Fig. Acetate, which has no toxic effects, may be activated to NADH + H+ acetyl CoA in the liver (where it can enter either the TCA cycle or the pathway for fatty acid synthesis). However, most of the acetate that is generated enters the blood and is O activated to acetyl CoA in skeletal muscles and other tissues (see Fig. Acetate is CH3C – O generally considered nontoxic and is a normal constituent of the diet. Acetate The other principal route of ethanol oxidation in the liver is the microsomal ethanol oxidizing system (MEOS), which also oxidizes ethanol to acetaldehyde Fig. The principal microsomal enzyme involved is a cytochrome P450 (ADH, alcohol dehydrogenase; ALDH, mixed-function oxidase isozyme (CYP2E1), which uses NADPH as an additional acetaldehyde dehydrogenase). This route accounts for only 10 to 20% of ethanol oxidation in a moderate drinker. Each of the enzyme activities involved in ethanol metabolism (alcohol dehydro- CH3CH2OH genase, acetaldehyde dehydrogenase, and CYP2E1) exist as a family of isoen- Ethanol zymes. Individual variations in the quantity of these isoenzymes influence a num- NADPH ber of factors, such as the rate of ethanol clearance from the blood, the degree of M + H+ + O E 2 inebriation exhibited by an individual, and differences in individual susceptibility to O the development of alcohol-induced liver disease. Alcohol Dehydrogenase O ER CH3C Alcohol dehydrogenase (ADH) exists as a family of isoenzymes with varying speci- H ficity for chain length of the alcohol substrate (Table 25. Ethanol is a small mol- Acetaldehyde ecule that does not exhibit much in the way of unique structural characteristics and, Fig. The reaction catalyzed by MEOS at high concentrations, is nonspecifically metabolized by many members of the (which includes CYP2E1) in the endoplasmic ADH family. The alcohol dehydrogenases that exhibit the highest specificity for reticulum. We have three genes for class I alco- hol dehydrogenases, each of which exists as allelic variants (polymorphisms). Isozymes of Medium-Chain-Length Alcohol Dehydrogenases Class Gene Sub-Unit Tissue Distribution Properties I ADH 1 Most abundant in liver and adrenal glands. ADH 2 lower levels in kidney, lung, colon, small intestine, Active only with ethanol. II ADH 4 Primarily liver, lower levels in GI tract Km of 34 mM for ethanol. III ADH 5 Ubiquitously expressed, but at higher Relatively inactive toward levels in liver. IV ADH 7 Present in highest levels in upper GI tract, gingiva Km of 28 mM. It is the most and mouth, esophagus, down to the stomach. Not active of medium-chain alcohol present in liver. Some activity toward ethanol CHAPTER 25 / METABOLISM OF ETHANOL 461 The class I alcohol dehydrogenases are present in high quantities in the liver, rep- The human has at least seven, and resenting approximately 3% of all soluble protein. These alcohol dehydrogenases, possibly more, genes that code for commonly referred to collectively as liver alcohol dehydrogenase, have low K s for specific isoenzymes of medium- m chain-length alcohol dehydrogenases, the ethanol between 0. Thus, the liver is the major site of major enzyme responsible for the oxidation ethanol metabolism and the major site at which the toxic metabolite acetaldehyde is of ethanol to acetaldehyde in the human. These different alcohol dehydrogenases Although the class IV and class II enzymes make minor contributions to ethanol have an approximately 60 to 70% identity metabolism, they may contribute to its toxic effects. Ethanol concentrations can be and are assumed to have arisen from a com- quite high in the upper GI tract (e.

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