Magdolna Hornyak, MD

• Professor, Interdisciplinary Pain Centre, University of
• Freiburg Medical Centre, Freiburg, Germany

Receives cortical input erectile dysfunction hypertension buy generic super p-force oral jelly 160mg on-line, provides negative feedback to cortex to modulate movement erectile dysfunction protocol download free super p-force oral jelly 160 mg with mastercard. Dopamine binds to D1 erectile dysfunction caused by radical prostatectomy cheap 160 mg super p-force oral jelly, stimulating the excitatory pathway impotence hernia discount 160mg super p-force oral jelly amex, and to D2, inhibiting the inhibitory pathway motion. Distorted appearance is due to certain body regions being more richly innervated and thus having cortical representation. Cerebral perfusion is primarily driven by Pco2 (Po2 also modulates perfusion in severe hypoxia). Damage by severe hypotension upper leg/upper arm weakness, defects in higher-order visual processing. Your eyes are above your ears, and the superior colliculus (visual) is above the inferior colliculus (auditory). All other nerves exit below (eg, C3 exits above the 3rd cervical vertebra; L2 exits below the 2nd lumbar vertebra). Spinal cord and associated tracts A Legs (Lumbosacral) are Lateral in Lateral corticospinal, spinothalamic tracts A. They may reemerge in adults following frontal lobe lesions loss of inhibition of these reflexes. T4 C6 T6 T10-at the umbilicus (important for early C7 T8 appendicitis pain referral). Internuclear ophthalmoplegia (impaired adduction of ipsilateral eye; nystagmus of contralateral eye with abduction). Wernicke-Korsakoff syndrome-Confusion, Ataxia, Nystagmus, Ophthalmoplegia, memory loss (anterograde and retrograde amnesia), confabulation, personality changes. Parinaud syndrome-paralysis of conjugate vertical gaze (rostral interstitial nucleus also involved). Intention tremor, limb ataxia, loss of balance; damage to cerebellum ipsilateral deficits; fall toward side of lesion. Frontal eye fields Paramedian pontine reticular formation Medial longitudinal fasciculus Dominant parietal cortex Nondominant parietal cortex Hippocampus (bilateral) Basal ganglia Subthalamic nucleus Mammillary bodies (bilateral) Gerstmann syndrome. Reduce risk with medical therapy (eg, aspirin, clopidogrel); optimum control of blood pressure, blood sugars, lipids; and treat conditions that risk (eg, atrial fibrillation). Can cause midline shift (yellow arrow in C), findings of "acute on chronic" hemorrhage (blue arrows in D). Bleeding E F due to trauma, or rupture of an aneurysm (such as a saccular aneurysm E) or arteriovenous malformation. Also seen with amyloid angiopathy (recurrent lobar hemorrhagic stroke in elderly), vasculitis, neoplasm. Typically occurs in basal ganglia G and internal capsule (Charcot-Bouchard microaneurysm of lenticulostriate vessels), but can also occur in cerebral hemispheres, brainstem, and cerebellum H. Wernicke aphasia is associated with right superior quadrant visual field defect due to temporal lobe involvement. Anterior cerebral artery Lenticulostriate artery Posterior circulation Anterior spinal artery Lateral corticospinal tract. Initial paresthesias followed in weeks to months by allodynia (ordinarily painless stimuli cause pain) and dysesthesia. Broca and Wernicke areas and arcuate fasciculus remain intact; surrounding watershed areas affected. Wernicke (receptive) Fluent Impaired Conduction Global Repetition intact Transcortical motor Transcortical sensory Transcortical, mixed Fluent Nonfluent Intact Impaired Nonfluent Fluent Nonfluent Intact Impaired Impaired Aneurysms Saccular (berry) aneurysm Abnormal dilation of an artery due to weakening of vessel wall. Other risk factors: advanced age, hypertension, smoking, race (risk in African-Americans). Usually clinically silent until rupture (most common complication) subarachnoid hemorrhage ("worst headache of my life" or "thunderclap headache") focal neurologic deficits. Can also cause symptoms via direct compression on surrounding structures by growing aneurysm. Common, associated with chronic hypertension; affects small vessels (eg, lenticulostriate arteries in basal ganglia, thalamus). Types: Simple partial (consciousness intact)- motor, sensory, autonomic, psychic Complex partial (impaired consciousness) Diffuse. Types: Absence (petit mal)-3 Hz spike-and-wave discharges, no postictal confusion, blank stare Myoclonic-quick, repetitive jerks Tonic-clonic (grand mal)-alternating stiffening and movement Tonic-stiffening Atonic-"drop" seizures (falls to floor); commonly mistaken for fainting Epilepsy-a disorder of recurrent seizures (febrile seizures are not epilepsy). Other causes of headache include subarachnoid hemorrhage ("worst headache of my life"), meningitis, hydrocephalus, neoplasia, giant cell (temporal) arteritis. Associated with hepatic encephalopathy, Wilson disease, and other metabolic derangements. Athetosis Slow, snake-like, writhing Basal ganglia movements; especially seen in the fingers Sudden, jerky, purposeless movements Sustained, involuntary muscle contractions High-frequency tremor with sustained posture (eg, outstretched arms), worsened with movement or when anxious Sudden, wild flailing of 1 arm +/- ipsilateral leg Slow, zigzag motion when pointing/extending toward a target Sudden, brief, uncontrolled muscle contraction Uncontrolled movement of distal Substantia nigra (Parkinson appendages (most noticeable disease) in hands); tremor alleviated by intentional movement Contralateral subthalamic nucleus (eg, lacunar stroke) Cerebellar dysfunction Basal ganglia Chorea = dancing. Chorea Dystonia Essential tremor Hemiballismus Intention tremor Myoclonus Jerks; hiccups; common in metabolic abnormalities such as renal and liver failure. Symptoms manifest between ages 20 and 50: chorea, athetosis, aggression, depression, dementia (sometimes initially mistaken for substance abuse). Alzheimer disease Widespread cortical atrophy (normal cortex B; cortex in Alzheimer disease C), especially hippocampus (arrows in B and C). Neurofibrillary tangles E: intracellular, hyperphosphorylated tau protein = insoluble cytoskeletal elements; number of tangles correlates with degree with dementia. Frontotemporal dementia (Pick disease) Early changes in personality and behavior (behavioral variant), or aphasia (primary progressive aphasia). Dementia and visual hallucinations ("haLewycinations") parkinsonian features Lewy body dementia Intracellular Lewy bodies A primarily in cortex. Rapidly progressive (weeks to months) dementia with myoclonus ("startle myoclonus"). Risk factors include female gender, obesity, vitamin A excess, tetracycline, danazol. Expansion of ventricles A distorts the fibers of the corona radiata triad of urinary incontinence, ataxia, and cognitive dysfunction (sometimes reversible). A B C Noncommunicating (obstructive) Noncommunicating hydrocephalus Hydrocephalus mimics Ex vacuo ventriculomegaly Osmotic demyelination Acute paralysis, dysarthria, dysphagia, diplopia, loss of consciousness. In contrast, correcting hypernatremia too quickly results in cerebral edema/herniation. Most often affects women in their 20s and 30s; more common in Caucasians living farther from equator. Neck flexion may precipitate sensation of electric shock running down spine (Lhermitte phenomenon). Periventricular plaques A (areas of oligodendrocyte loss and reactive gliosis) with preservation of axons.

Value approaching 100% is desirable for ruling in disease and indicates a low falsepositive rate tobacco causes erectile dysfunction order super p-force oral jelly 160 mg with mastercard. Probability that a person who has a positive test result actually has the disease impotence restriction rings generic super p-force oral jelly 160mg otc. Probability that a person with a negative test result actually does not have the disease erectile dysfunction treatment seattle buy 160mg super p-force oral jelly fast delivery. The difference in risk between exposed and unexposed groups erectile dysfunction young age treatment buy generic super p-force oral jelly 160 mg online, or the proportion of disease occurrences that are attributable to the exposure (eg, if risk of lung cancer in smokers is 21% and risk in nonsmokers is 1%, then 20% of the lung cancer risk in smokers is attributable to smoking). Number of patients who need to be exposed to a risk factor for 1 patient to be harmed. Prevalence > incidence for chronic diseases, due to large # of existing cases (eg, diabetes). Precision vs accuracy Precision (reliability) the consistency and reproducibility of a test. Berkson bias-study population Randomization selected from hospital is Ensure the choice of the right less healthy than general comparison/reference group population Healthy worker effect-study population is healthier than the general population Non-response bias- participating subjects differ from nonrespondents in meaningful ways Patients with disease recall exposure after learning of similar cases Decrease time from exposure to follow-up Use objective, standardized, and previously tested methods of data collection that are planned ahead of time Use placebo group Performing study Recall bias Awareness of disorder alters recall by subjects; common in retrospective studies. Measures of dispersion Standard deviation = how much variability exists in a set of values, around the mean of these values. Standard error = an estimate of how much variability exists in a (theoretical) set of sample means around the true population mean. If there is an even number of values, the median will be the average of the middle two values. Median Mean Mode Statistical hypotheses Null (H0) Hypothesis of no difference or relationship (eg, there is no association between the disease and the risk factor in the population). Hypothesis of some difference or relationship (eg, there is some association between the disease and the risk factor in the population). Stating that there is not an effect or difference when none exists (null hypothesis not rejected). Stating that there is an effect or difference when none exists (null hypothesis incorrectly rejected in favor of alternative hypothesis). Stating that there is not an effect or difference when one exists (null hypothesis is not rejected when it is in fact false). You can never "prove" the alternate hypothesis, but you can reject the null hypothesis as being very unlikely. Confidence interval Range of values within which the true mean of the population is expected to fall, with a specified probability. Example: comparing the mean blood pressure between members of 3 different ethnic groups. Example: comparing the percentage of members of 3 different ethnic groups who have essential hypertension. Checks differences between 2 or more percentages or proportions of categorical outcomes (not mean values). The closer the absolute value of r is to 1, the stronger the linear correlation between the 2 variables. Coefficient of determination = r 2 (amount of variance in one variable that can be explained by variance in another variable). Patient must be informed that he or she can revoke written consent at any time, even orally. Exceptions to informed consent: Patient lacks decision-making capacity or is legally incompetent Implied consent in an emergency Therapeutic privilege-withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity Waiver-patient explicitly waives the right of informed consent Consent for minors A minor is generally any person < 18 years old. In general, parental consent should be obtained, but exceptions exist for emergency treatment (eg, blood transfusions) or if minor is legally emancipated (eg, married, self supporting, or in the military). Decision-making capacity Physician must determine whether the patient is psychologically and legally capable of making a particular healthcare decision. Note that decisions made with capacity cannot be revoked simply if the patient later loses capacity. Capacity is determined by a physician for a specific healthcare-related decision (eg, to refuse medical care). Competency is determined by a judge and usually refers to more global categories of decision making (eg, legally unable to make any healthcare-related decision). If patient was informed, directive was specific, patient made a choice, and decision was repeated over time to multiple people, then the oral directive is more valid. Specifies specific healthcare interventions that a patient anticipates he or she would accept or reject during treatment for a critical or life-threatening illness. Patient designates an agent to make medical decisions in the event that he/she loses decisionmaking capacity. Other resuscitative measures that follow (cardioversion, intubation) are also typically avoided. Written advance directive Medical power of attorney Do not resuscitate order Surrogate decisionmaker If a patient loses decision-making capacity and has not prepared an advance directive, individuals (surrogates) who know the patient must determine what the patient would have done. The patient may voluntarily waive the right to confidentiality (eg, insurance company request). Attempt to identify the reason for nonadherence and determine his/her willingness to change; do not coerce the patient into adhering and do not refer him/her to another physician. Attempt to understand why the patient wants the procedure and address underlying concerns. Provide written instructions; attempt to simplify treatment regimens; use teach-back method (ask patient to repeat regimen back to physician) to ensure comprehension. Explain that as long as the patient has decisionmaking capacity and does not indicate otherwise, communication of information concerning his/her care will not be withheld. However, if you believe the patient might seriously harm himself or others if informed, then you may invoke therapeutic privilege and withhold the information. The patient retains the right to make decisions regarding her child, even if her parents disagree. Provide information to the teenager about the practical issues of caring for a baby. Encourage discussion between the teenager and her parents to reach the best decision. In the overwhelming majority of states, refuse involvement in any form of physicianassisted suicide. If it is serious, suggest that the patient remain in the hospital voluntarily; patient can be hospitalized involuntarily if he/she refuses. Suggest that the patient speak directly to that physician regarding his/her concerns. If the problem is with a member of the office staff, tell the patient you will speak to that person. Regardless of the outcome, a physician is ethically obligated to inform a patient that a mistake has been made. A terminally ill patient requests physician assistance in ending his/her own life. Discuss all treatment options with patients, even if some are not covered by their insurance companies. Do not necessarily pressure patient to leave his or her partner, or disclose the incident to the authorities (unless required by state law). Find out why and allow patient to do so as long as there are no contraindications, medication interactions, or adverse effects to the new treatment. Gently explain to family that there is no chance of recovery, and that brain death is equivalent to death. Bring case to appropriate ethics board regarding futility of care and withdrawal of life support. Generally, decline gifts and sponsorships to avoid any appearance of conflict of interest. Work with the patient by either explaining the treatment or pursuing alternative treatments. A pharmaceutical company offers you a sponsorship in exchange for advertising its new drug. Emergent care can be refused by the are unresponsive following a car healthcare proxy for an adult, particularly when patient preferences are known or accident and are bleeding internally. Children not meeting milestones may need assessment for potential developmental delay.

By the 1900s erectile dysfunction drugs covered by insurance buy super p-force oral jelly 160 mg with visa, infant scurvy was eradicated when heated formulas (boiling destroys vitamin C) was supplemented with fresh fruits or vegetables erectile dysfunction systems buy super p-force oral jelly 160mg overnight delivery. Pathology/Histopathology Rickets is caused by a deficiency or abnormal metabolism of vitamin D or abnormal excretion of phosphate leading to bony deformities and hypocalcemia (Table 1) impotence beavis and butthead buy discount super p-force oral jelly 160 mg on line. The physis is a region of chondrocyte hypertrophy erectile dysfunction oil treatment buy generic super p-force oral jelly 160mg on line, proliferation and vascular invasion which then converts into primary bone spongiosa. If calcium or phosphorus is deficient, the growth plate thickens, the chondrocytes become disorganized, and osteoid accumulates. Vitamin D requires activation to regulate absorption and renal retention of calcium and phosphorus, and modulates osteoblastic function. Dietary vitamin D from plants is known as ergocalciferol-vitamin D2 and that from animal is known as cholecalciferol-vitamin D3. Hydroxylation at the first site takes place in the kidneys and is regulated by 25-hydroxy D-1 alpha hydroxylase. There is a net decrease in bone mass unless adequate amounts of calcium and phosphorus are supplemented. This is particularly true if breast milk is the primary source of nutrition as it contains less than half of the needed calcium and phosphorus for growing premature infants. Vitamin C is required for the formation of hydroxyproline, crucial for collagen formation which makes up 90% of mature boney matrix. Lack of collagen severely affects bone formation in childhood, resulting in scurvy and osteoporosis in adults. Defective collagen synthesis also leads to poor dentine formation, hemorrhage of gums, and diffuse bleeding. The pathophysiological changes in scurvy are the results of depression of normal cellular activity. Osteoblastic activity is suppressed with failure to form osteoid, yet resorption continues with resultant osteoporosis. At the physis, cartilage proliferation is decreased yet mineralization is unimpaired, thus the zone of provisional calcification appears wide and dense. Changes around the epiphyseal ossification center result in a thin ring of increased density. Vascular invasion in the zone of provisional calcification with suppressed osteoblastic activity results in decreased density in the zone of primary and secondary spongiosa. The zone of provisional calcification extends beyond the margins of the metaphysis resulting in periosteal elevation and marginal spur formation. Increased capillary fragility results in subperiosteal hemorrhage elevating the periosteum. Intraarticular hemorrhage is rare as periosteal attachment to the growth plate is strong. V 1954 Vitamin Deficiency Clinical Presentation Rickets: With the introduction of dietary supplements, the incidence of rickets has decreased significantly. Cases still occur, particularly in breastfed infants with limited sunlight exposure who are not supplemented with vitamins. Muslim women wearing veils are at high risk of vitamin D deficiency secondary to underexposure to sunlight. Blacks are more affected than whites possibly due to decreased penetration of ultraviolet light. Patients who are elderly or alcoholic with diets lacking in fresh fruits and vegetables are most vulnerable. More specific symptoms include bleeding gums, pseudoparalysis, with subperiosteal bleeding causing severe pain. The enlarged ends of the ribs can be palpable at the costochondral junction clinically, called "the rachitic rosary. Basilar invagination, indistinct sutures, delayed tooth eruption, and premature craniostenosis can occur. The first radiographic changes appear in rapidly growing distal ends of the radius and ulna. The metaphyseal margin becomes indistinct then frayed with widening of the growth plate. Weight bearing and stress on uncalcified bone result in splaying and cupping of the metaphysis. Table 2 Key findings in rickets Widening and cupping of the metaphysis Fraying of the metaphysis Craniotabes Bowing of the long bones Scoliosis Triradiate pelvis-impression of femur into pelvis- protrusion acetabuli Vitamin Deficiency. Following treatment, there is ossification of the provisional zone of calcification. The radiolucent metaphyseal bands become more prominent as the zone of provisional calcification becomes denser. Calvarial thickening develops with frontal and parietal bossing and premature suture closure. During healing, there is extensive periosteal new bone formation along the cornices of the diaphyses. Angulation deformities secondary to pathological fractures can result in genu valga or varum. Cortical thickening may persist though remodeling of bowing deformities eventually occurs. The knee, wrist, proximal humerus, and sternal ends of the ribs are typical sites of involvement (Table 3). In the early phase, the cortex becomes thin and the trabecular structure of the medulla atrophies and develops a ground-glass appearance. The zone of provisional calcification becomes dense and wide referred to as the white line of Frankle. As scurvy becomes advanced, a zone of rarefaction occurs at the metaphysis below the white line of Frankle. This transverse band of radiolucency beneath the zone of calcification is called the Trummerfeld zone of lucency. The zone involves the lateral aspects of the white line, resulting in triangular defects called the corner sign of park. This region has multiple microscopic fractures and can collapse with impaction of the calcified cartilage onto the shaft. Subperiosteal hemorrhages are frequent and are most commonly noted Vitamin Deficiency. Extensive subperiosteal hemorrhages have calcified, resulting in significantly elevated periosteum. Rarely, subperiosteal hematomas develop on the flat bones of the orbit causing proptosis. The raised periosteum layers the periphery of the hematoma with subperiosteal bone. Multiple vitamin deficiencies can modify the radiologic appearance of growing bone. When scurvy and rickets are both present, scurvy findings are predominant because of diminished osteoblastic activity. Scurvy could potentially be mistaken for nonaccidental trauma when corner fractures and subperiosteal elevation is noted. V Diagnosis Rickets: the diagnosis of vitamin D deficiency is made on clinical, radiographic, and laboratory values. The rarefaction and irregular fraying of the zone of provisional calcification are virtually diagnostic but the underlying cause needs to be evaluated via biochemical and clinical assessment. Dietary history, medication history, and measurement of creatinine and liver enzymes may help pinpoint the cause. Alkaline phosphatase is usually increased and is an excellent marker of disease activity. Scurvy: Radiologic findings of scurvy are diagnostic with laboratory tests not significantly helpful. It uses radiopaque contrast material that is instilled into the bladder via puncture or catheterization to fluoroscopically examine the bladder and-during voiding-the urethra.

Collagen and elastic fibers embedded in the ground substance impart tensile strength and elasticity impotence women 160mg super p-force oral jelly overnight delivery. Cartilage differs from other connective tissues in that it lacks nerves erectile dysfunction journals cheap super p-force oral jelly 160 mg otc, blood and lymphatic vessels and is nourished entirely by diffusion of materials from blood vessels in adjacent tissues erectile dysfunction zoloft discount super p-force oral jelly 160 mg line. Although relatively rigid impotence treatment options order super p-force oral jelly 160 mg with mastercard, the cartilage matrix has a high water content (about 75%) and is freely permeable, even to fairly large particles. Classification of cartilage into hyaline, elastic, and fibrous types is based on differences in the abundance and type of fibers in the matrix. The cells of cartilage are called chondrocytes and reside in small spaces called lacunae scattered throughout the matrix. The cells generally conform to the shape of the lacunae in which they are contained. Deep in the cartilage the cells and their lacunae usually appear rounded in profile, whereas at the surface, they are elliptical, with the long axis parallel to the surface. Chondrocytes often occur in small clusters called isogenous groups that represent the offspring of a single cell. In the usual preparations, the cells show an irregular outline and appear shrunken and pulled away from the walls of the lacunae. Electron microscopy reveals that each cell completely fills the lacunar space and sends short processes into the surrounding matrix, but neighboring cells do not touch one another. The cytoplasm shows the usual organelles as well as lipid and glycogen inclusions. In growing chondrocytes the Golgi complex and endoplasmic reticulum are well developed. In fresh cartilage and in routine histologic sections, the matrix appears homogeneous because the ground substance and the collagen fibers embedded within it have the same refractive index. The collagen in hyaline cartilage rarely forms bundles but is present as a feltwork of slender unit fibrils in which the banding pattern shows variable periodicities or even is lacking. The ground substance consists mainly of proteoglycans, the specific glycosaminoglycans of cartilage being chondroitin-4- and chondroitin-6sulfate, keratan sulfate, and a small amount of hyaluronic acid. The proteoglycans are responsible for the basophilic properties of the ground substance. Chondrocalcin, a calciumbinding glycoprotein, also has been demonstrated in the ground substance of hyaline cartilage. The matrix around each lacuna and isogenous group stains more deeply than elsewhere, forming the territorial matrix. Except for the free surfaces of articular cartilages, hyaline cartilage is enclosed by a specialized sheath of connective tissue called the perichondrium. The outer layers of the perichondrium consist of a well vascularized, dense, irregular connective tissue that contains elastic and collagen fibers and fibroblasts. Where it lies against cartilage, the perichondrium is more cellular and passes imperceptibly into cartilage. The slender collagen unit fibrils of the cartilage matrix blend with the wider, type I collagen unit fibrils of the perichondrium. Perichondrial cells adjacent to the cartilage retain the capacity to form new cartilage. Collagen fibers of the type found in hyaline cartilage also are present but are masked. Deep in the cartilage, elastic fibers form a dense, closely packed mesh that obscures the ground substance, but beneath the perichondrium, the fibers form a looser network and are continuous with those of the perichondrium. The chondrocytes are similar to those of hyaline cartilage and elaborate the elastic and collagen fibers. Elastic cartilage is more flexible than hyaline cartilage and is found in the external ear, auditory tube, epiglottis, and in some of the smaller laryngeal cartilages. Cancellous (spongy) bone consists of irregular bars or trabeculae of bone that branch and unite to form a three-dimensional, interlacing network of boney rods, delineating a vast system of small communicating spaces that in life are filled with bone marrow. Trabeculae of spongy bone from weight bearing lower limb bones do not form a random network but occur in a precisely organized pattern along compression and tension stress lines. This strut-like arrangement of the trabeculae contributes to the strength of these bones. Compact (dense) bone appears as a solid, continuous mass in which spaces cannot be seen with the naked eye. In a typical long bone the shaft or diaphysis appears as a hollow cylinder of compact bone enclosing a large central space called the marrow cavity. The ends of the long bones, the epiphyses, consist mainly of cancellous bone covered by a thin layer of compact bone. The small intercommunicating spaces in the spongy bone are continuous with the marrow cavity of the shaft. Except over articular surfaces and where tendons and ligaments insert, bone is covered by a dense irregular fibroelastic connective tissue called the periosteum. The marrow cavity of the diaphysis and the spaces within spongy bone are lined by endosteum, which is similar to periosteum but is thinner and not as fibrous. Both the periosteum and endosteum have the ability to form new bone under appropriate stimulation. Fibrous Cartilage Fibrous (or fibro-) cartilage represents a transition between dense connective tissue and cartilage. It consists of typical cartilage cells enclosed in lacunae, but only a small amount of ground substance is present in the immediate vicinity of the cells. The chondrocytes lie singly, in pairs, or in short rows between bundles of dense collagen fibers the unit fibrils of which that show the 64-nm banding pattern typical of type I collagen. Fibrous cartilage always lacks a perichondrium and merges into hyaline cartilage, bone, or dense fibrous connective tissue. It occurs in the intervertebral discs, in some articular cartilages, in the symphysis pubis, and at sites of attachment of certain tendons to bone. However, in bone the matrix is mineralized and forms a dense, hard, unyielding substance with high tensile, weight-bearing, and compression strength. Despite its strength and rigidity, bone is a dynamic, living tissue constantly turning over, constantly being renewed and reformed throughout life. Small, ovoid spaces, the lacunae, occur rather uniformly within and between the lamellae, each occupied by a single bone cell or osteocyte. Slender tubules called canaliculi radiate from each lacuna and penetrate the lamellae to link up with the canaliculi of adjacent lacunae. Most are arranged concentrically around a longitudinal space to form cylindrical units that run parallel to the long axis of the bone. Osteons vary in size and consist of 8 to 15 concentric lamellae that surround a wide space occupied by blood vessels. In longitudinal sections, an osteon appears as plates of boney matrix running parallel to the slitlike space of the vascular channel. Throughout its thickness, compact bone contains a number of osteons running side by side. Other lamellae appear as angular, irregular bundles of lamellar bone that fill the spaces between osteons. Osteons and interstitial lamellae are outlined by a refractile line, the cement line, which consists of modified matrix. At the external surface of the bone, immediately beneath the periosteum, several lamellae run around the circumference of the entire bone. A similar but less well-developed system of lamellae is present on the inner surface, just beneath the endosteum. These two systems of lamellae are the outer and inner circumferential lamellae, respectively. The longitudinally oriented channels at the center of osteons are the Haversian canals. Thus, the nutritional needs of compact bone are met by a vast, continuous network of vascular channels. Canaliculi adjacent to a Haversian canal open into the perivascular space, and the canalicular system brings all the lacunae within that osteon into communication with the canal. Spongy bone shows a lamellar structure also but differs from compact bone in that it is not usually traversed by blood vessels.

Lateral approaches to the cervical spine for the treatment of radicular syndromes have historical interest but are sometimes used for more complex pathologies compressing the exiting root laptop causes erectile dysfunction generic super p-force oral jelly 160 mg without a prescription. The anterior approach presently comprises more than 90% of all surgical techniques employed in cervical radicular syndromes erectile dysfunction in diabetes medscape generic super p-force oral jelly 160mg with mastercard. The main reason for this is the origin of the pathology anterior to the root and cord erectile dysfunction treatment diet 160mg super p-force oral jelly otc, and the sparing nature of the technique leaving intact all spinal anatomical structures except for the disc erectile dysfunction over the counter drugs generic super p-force oral jelly 160 mg line. The latter is removed including osteophytes which may be present, and the posterior longitudinal ligament is Synonyms Laminectomy; (Micro)discectomy Definition A radicular syndrome is characterized by pain radiating in the dermatome of a spinal nerve root. Pain may be accompanied by one or more of the following: lumbar muscle spasm, reflex abnormalities, motor and sensory disturbances. Surgical therapy for a radicular syndrome refers to all procedures which have the goal to decompress the exiting nerve roots. Pathology Disc herniations are the most frequent cause of a radicular syndrome, followed by stenosis of the lateral recess and occasionally narrowing of the neuroforamen. The latter occur more frequently in the cervical spine in elderly populations, where progressive disc degeneration leads to spine deformities with compression at the spinal outlet of nerve. Disc herniations can be divided into contained and uncontained protrusions of nuclear material, and the latter may give rise to a sequester or free fragment of disc material. In the past, autologous bone from the iliac crest was used to fill the gap in the open disc space. Pain in the iliac crest area directed surgeons to the use of cement and later to cages filled with bone, the latter followed by an anterior plate and screw fixation of both vertebrae in some countries. Recently, disc prostheses have been used with the goal of preserving cervical mobility and thus preventing future disc degeneration at adjacent levels. To emphasize the variety of procedures used for the same disease, it can be noted that many surgeons prefer to perform a discectomy without any graft, cement, cage, or prosthesis. Lack of scientific data and huge industrial influence are the main reasons for this lack of consensus. Randomized trials are started to provide better insight in the value and (cost-)effectiveness of the different techniques. The timing of surgery is subject of a randomized trial in Europe (2), whereas a trial in the United States sets out to determine the effectiveness of surgery compared to conservative treatment (3). Surgical interventions can be divided into percutaneous techniques indirectly decompressing the nerve root by intradiscal action and posterior surgical techniques, actually removing the disc herniation and therefore direct decompression. After the first description in 1934 of removal of a lumbar disc herniation by laminectomy (4), this technique was the method of choice for many years. The goal was a complete posterior decompression of the dural sac and removal of as much disc material as possible. After the introduction of the microscope for intracranial procedures, application of this technique to spine surgery is followed. The major difference with the classical broad laminectomy is the less invasive approach with limited bone removal. Randomized trials have not shown any benefit of the microdiscectomy when compared with classical approach (5). Recent reports deal with selective removal of extruded material leaving the disc intact. This procedure lacks evidence of effectiveness, so far prohibiting worldwide implementation. Use of an endoscope facilitates angulation of the optics in the spinal canal, but most surgeons use the microscope. The main disadvantage of all new techniques is the relatively high recurrent rate of disc herniations of up to 10%. Until randomized controlled trials present at least comparable effectiveness and a low recurrence rate, the classical microsurgical approach is the gold standard. Thoracic spine Thoracic disc herniations are frequently ossified and have a very low incidence. Furthermore, patients with a thoracic disc herniation most frequently present with spinal cord compression, with the risk of severe motor and sensory disturbances of the lower extremities and bladder dysfunction. Probably, because of the calcifications within thoracic disc herniations, posterior approaches have had poor results with frequent neurological complications leading to a more severe deficit compared to the preoperative status. Because of the low incidence of thoracic disc herniations patients are treated in specialized centers, reducing the risks of surgery. The posterolateral approach employs costotransversectomy, and provides access by removing the proximal rib and transverse process. This classical approach has recently been replaced by a less invasive microscopic approach. Large thoracotomy approaches with division of the diaphragm at the disc level between the 12th thoracic and 1st lumbar vertebrae have nowadays been replaced by thoracoscopic techniques and more recently by mini-open thoracotomies using an incision of less than 4 cm and normal ventilation of both lungs. One in every 1586 Radiculopathy scan may be beneficial when bony compression is suspected or even an ossified posterior longitudinal ligament. The surgical procedure may be altered depending on the presence and location of calcifications. The same holds true for the thoracic spine, where some surgeons also prefer to have spinal angiography performed to localize the Adamkiewicz artery, the major spinal cord feeder, before deciding on the side of a transthoracic approach. Postoperative imaging is done frequently as a routine measure in thoracic and cervical pathology, but after surgery of lumbar disc herniations only when complaints persist or recur. It represents the most assessed method for percutaneous thermal ablation of hepatic malignancies. Radiographic Iodinated Contrast Media A radiographic iodinated contrast medium is an imaging contrast agent in which iodine, bound to organic molecules, provides the increased attenuation to X-rays required for visualization. It is characterized by episodic attacks of vasospasm caused by closure of the small arteries of the most distal parts of the extremity in response to cold or emotional stimuli. Brachial Ischemia Radionuclide Cystography Scintigraphic examination with direct or indirect administration of radionuclide for exclusion or detection of vesicoureteral reflux. Contrast Media, Ultrasound, Applications in Vesicoureteral Reflux Receptor Imaging Receptor Studies, Neoplasms Radiotracer A very small mass of the molecule of interest that is radiolabelled to evaluate the behaviour of the compound of interest. It manifests clinically with acute peripheral facial nerve paralysis and vesicular eruptions over the ear, face and neck. Facial Nerve Palsy Receptor imaging; Targeted tumor imaging Definitions Receptors are proteins on the cell membrane, in the cytoplasm, or in the nucleus of the cell that bind ligands such as neurotransmitters, hormones, or others. This interaction between the receptor and its ligand initiates a cellular response. The profile of expressed receptors is different for cells with different functions. In many neoplasms, the cellular production of certain receptors is upregulated, and therefore they are overexpressed. Agonists initiate a cellular response after their binding to the receptor, whereas antagonists occupy the binding site of a receptor without causing a response. Typically the skin discoloration follows a time course with primary paleness, then a livid aspect, and subsequent reddening in the phase of painful hyperemia. Connective Tissue Disorders, Musculoskeletal System 1588 Receptor Studies, Neoplasms Characteristics Nuclear medicine offers the opportunity to visualize receptors by labeling a ligand with a radionuclide suitable for imaging. The radiolabeled ligands used are mainly molecules similar to the natural ligand, often peptides. Beside peptides, other ligands such as antibodies, parts of antibodies, or artificial molecules can be used. These ligands can be from both categories, either receptor agonists or receptor antagonists. Antagonists have the disadvantage that they are mostly not internalized into the cell, which often results in a shorter retention time of the radioactivity in the target. Radiolabeled ligands have to fulfill a number of prerequisites such as metabolic stability, high receptor affinity, favorable toxicity profile, and stable binding of the radionuclide to be useful for in vivo imaging. Not only the radiolabeled ligand but also the receptor must fulfill a number of prerequisites. To visualize a tumor, the target receptor has to be overexpressed on the tumor cells.

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