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By L. Jaroll. Adelphi University. 2018.

Various common surgical procedures include: Tendo-achillis lengthening-for equinus correction finasteride 5 mg without a prescription hair loss 2year old, Adductor tenotomy – to correct scissoring gait Split tibialis anterior transfer for inversion foot Tibialis posterior tendon transfer- for foot drop buy 1mg finasteride with visa hair loss 4 months after delivery, Egger’s operation/Fractional release of hamstrings (Tendon lengthening/tenotomies and capsulotomies)-for knee contracture release, Tripple arthrodesis for talipes equino-varus correction in mature feet. Flexor pronator release and transfer of flexor carpi ulnaris to the wrist dorsiflexors for contracture of flexor and pronator muscle group. Sever’s and Fairbank operation and derotation osteotomy of humerus- for internal rotation contracture at shoulder etc All the surgeries should be performed by the experienced surgeon and standard text book on the subject should be available in the operation theatre for the reference. Introduction: A form of spondyloarthritis, is a chronic, inflammatory arthritis and autoimmune disease. It mainly affects joints in the spine and the sacroiliac joint in the pelvis, and can cause eventual fusion of the spine. Case Definition: The typical patient is a young male, aged 20–40, however the condition also presents in females. These first symptoms are typically chronic pain and stiffness in the middle part of the spine or sometimes the entire spine, often with pain referred to one or other buttock or the back of thigh from the sacroiliac joint. Patient needs to be counselled regarding the chronic nature of the disease and need for regular treatment, possible complications and possible treatment options and chances of improvement. Clinical diagnosis: 111 chronic pain and stiffness in the middle part of the spine or sometimes the entire spine, often with pain referred to one or other buttock or the back of thigh from the sacroiliac joint. In 40% of cases, ankylosing spondylitis is associated with an inflammation of the eye (iritis and uveitis), causing redness, eye pain, vision loss, floaters and photophobia. Any 2 out of first four criteria strongly indicate presence of Ankylosing Spondylitis even in the absence of xray and lab investigations. Physical Therapy – Patients to be encouraged to undertake active and passive range of motion exercises for all joints to maintain and prevent the progression of loss of mobility. Deep breathing exercises (Pranayaam) should be promoted to improve chest function. Referral criteria: For further evaluation and management of cases not responding to conventional therapy. Introduction: Benign bone tumour, vascular and very painful, about 1 cm in size; elicits sclerotic reaction by the parent bone when the lesion is in the cortical bone; In cancellous bone the lesion is limited by a thin rim of sclerotic bone; in the spine it can cause scoliosis; if the lesion is in the metaphysis which is intraarticular can produce symptoms of arthritis; If the lesion is in the evolving stage it may not be seen routine plain radiography. Situation 1: Non metro hospital: 116 a) clinical diagnosis may be difficult b) Investigation X-ray c) Treatment may be difficult d) referral criteria – suspicion, inability to diagnose Situation 2. Histopathologist, Facilities for surgery 3) Name of the condition: Benign Bone tumeour – Osteoblastoma I. Non metro Hospital a) clinical diagnosis – nothing specific b)Investigation –X-ray c)Referral criteria: If facilities and know-how are not available for curettage and bone grafting Situation 2: a)clinical Diagnisis is difficult. Introduction: Benign bone tumour arising from chondroblasts; usually present in the small bones of hands and feet and asymptomatic for long time; patient presents usually with a pathological fracture or sometimes pain. Differential Diagnosis: Aneurysmal bone cyst, Tubercular dactylitis, Giant cell tumour, clear cell chondrosarcoma & acrometastases. Introduction: Benign cartilaginous tumours; the former is also called “Codman’s Tumour”. Usually seen in the metaphyseal region of immature skeleton and most of the times it is asymptomatic. It may be an incidental finding in a x-ray taken for some other purpose or bigger lesions may present as pathological fractures.

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Definition Brain death is defined as the irreversible loss of all function of the brain order finasteride 1mg overnight delivery hair loss emedicine, including the brainstem buy discount finasteride 1 mg line hair loss in men quilting. The three essential findings to confirm brain death are coma (known irreversible cause), absence of brainstem reflexes, and apnea. Once brain death criteria are met a person clinically determined to be brain dead is legally dead in the context of organ donation under the Transplantation of Human Organ Act 1994. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnea test, are conclusively performed. In the absence of either complete clinical findings consistent with brain death, or confirmatory tests demonstrating brain death, brain death cannot be diagnosed. Brain death test  Sufficient time period has been passed to exclude possibility of possible recovery of meaningful neurological function, several hours to days as per clinical factors. Ocular movement  Absent oculocephalic reflex (doll’s eye )  Absent cold caloric responses (vestibulo-ocular reflex) Absent Facial sensory and motor response Absent Pharyngeal reflex and Tracheal reflex  Absence of gag reflex. Observation period between two examination Depends on the age of the patient;  7 days to 2 month old minimum 48 hr interval. Communication with family and further decision making After the clinical criteria of brain death have been met, the physician should inform the next of kin, who can be approached about organ donation. Counseling  The family should be counseled that the patient cannot recover  Family should be counseled for organ donation  If the patient cannot become an organ donor, withholding or withdrawing of life support may be discussed with the family. Referral Criteria  If the patient is a potential organ donor, he should be transferred to a tertiary level centre that is certified by the competent authority and is capable of supporting the brain dead organ donor  If in some cases further diagnostic studies are required to confirm brain death o Difficulty to determine coma. Supportive treatment should start early as soon as brain death has been recognized irrespective of the consent. Switch the focus of the management for elevated intracranial pressure and brain protection, to preservation of organ function and optimization of tissue oxygen delivery. Hemodynamic support Hypertension  Hypertension and bradycardia preceding brain death characterize the Cushing’s response. Thyroid hormone replacement  Thyroid hormone administration typically with T3 (triiodothyronine) which is the active form of thyroid hormone. Coagulopathy  If clinically significant mucocutaneous bleeding, treatment with appropriate blood components is required. Absolute Contraindications to organ donation  Malignancy (except primary brain tumors, low grade skin malignancies and carcinoma in situ of the cervix). Conclusion A severe shortage of organs the world over has led to increased pressure on the intensive care staff for early identification of the brain dead donor and optimum management of this condition. The diagnosis of brain death as per the Transplantation Human Organ Act 1994 is based on simple clinical bedside tests,no need of routine confirmatory test. This Act has made it possible in India to use this pool of patients for organ retrieval and transplantation. The process of organ donation and transplantation requires co-ordination between multidisciplinary teams operating almost simultaneously and sometimes in different locations like getting surgeons from different specialties together for both donor and recipient surgery. Further reading  Evidence-based guideline update: Determining brain death in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology Eelco F. N Engl J Med 2008; 359:674-675  Transcranial Doppler Ultrasonography to confirm brain death: a meta-analysis Louisa M. Simini Intensive Care Med (1995) 21:657-662  Brain death: timing of apnea testing in primary brain stem lesion, G.

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Evidence-based nutrition guidelines for the prevention and management of diabetes 15 Nutrition recommendations for people with diabetes Diet There is little evidence for the ideal macronutrient composition of the diet in the management of hyperglycaemia in Type 2 diabetes discount finasteride 1mg online hair loss vitamin deficiency. Small generic 1 mg finasteride with amex hair loss cure pennsylvania, short term intervention studies investigating the relationship between macronutrients and glycaemic control have reported contradictory results [112, 113, 114]. Epidemiological evidence has shown a relationship between high fat intake, high saturated fat intake and raised HbA1c levels [115], however intervention studies have failed to show any association between the type and amount of fat in meals and post-prandial glucose response [116, 117, 118, 119, 120, 121, 122]. It is unclear what ideal proportion of macronutrients to recommend for optimal glycaemic control for Type 2 diabetes, but total energy intake and weight loss are signifcant. Monounsaturated fat can be substituted for carbohydrate without detrimental effect to either lipids or glycaemic control, but saturated fat should be minimised [116, 117, 118, 120]. A modest reduction in carbohydrate intake is associated with improvements in glycaemic control and low carbohydrate diets can be particularly effective if associated with weight loss. The effcacy of carbohydrate counting in those individuals with Type 2 diabetes treated with insulin is largely unknown. Post-prandial glucose levels have been shown to be reduced on high fbre diets (>20g /1,000 kcal) but changes in fasting plasma glucose and lower average plasma glucose levels are not signifcant [128]. Short term studies have demonstrated little or no effect on blood glucose, insulin or HbA1c [104, 128, 129,130,131]. Uncertainties remain over the most effective dietary intervention to promote successful weight loss [133] and the gold standard, the randomised controlled trial, is rarely employed to compare different dietiery interventions head-to-head. Low-fat diets This strategy is the most widely employed in research studies and has generated the greatest amount of evidence. A recent large trial in the United States has shown that lifestyle interventions, including a low-fat diet, signifcantly reduced body weight, HbA1c and cardiovascular risk factors and these positive changes could be maintained over four years [134]. Low-carbohydrate diets Low-carbohydrate diets have created some controversy, but both a recent review and meta-analysis suggest that they are associated with signifcant reductions in body weight and improvements in glycaemic control [121, 135]. It has been shown that the main mode of action of low carbohydrate diets is simply a reduction in energy intake due to carbohydrate restriction [136]. Systematic reviews have reported that although these diets may be more effective than comparison diets over the short-term, there is little published evidence from studies in people without diabetes showing beneft over the longer term [44, 137]. Concern has been expressed about the potential adverse effects of these diets, especially on cardiovascular risk, but there remains no evidence of harm over the short term [137]. Meal replacements Meal replacements consist of liquid shakes, soups or bars designed to be eaten in place of one or two meals daily. A meta-analysis reported that partial meal replacements produced greater weight loss than a reduced energy diet over the short term (six months) [139]. Commercial diet programmes There is an absence of published evidence for the effect of commercial weight loss programmes in people with diabetes. These programmes utilise a variety of interventions including group therapy, dietary advice and physical activity. Physical activity Physical activity in isolation is not an effective strategy for weight loss in people with Type 2 diabetes [140] unless 60 minutes per day is undertaken [141]. However, evidence shows that a combination of diet and physical activity results in greater weight reduction than diet or physical activity alone [142]. Physical activity does have positive effects on cardiovascular risk and leads to signifcant reductions in diastolic blood pressure, triglycerides, fasting glucose [143] and glycated haemoglobin [140, 144].

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After potentials • Depolarization after potentials: The membrane potential for a brief period becomes more positive than the resting membrane potential and the cell 1 mg finasteride amex hair loss female, therefore discount 1mg finasteride hair loss for women, is slightly more excitable than normal. Action potentials for nerves are very brief, lasting only about 2-3 milliseconds, and the nerve cell is almost instantly ready again to conduct the next potential. Ionic basis of the action potential The different phases of the action potential are correlated with the following changes in ionic influxes: (See figure 22 & 23). Consequently, the increase in potassium conductance / permeability starts a little later and lasts longer. The outward flow of the potassium ions slows the rise of the potential, then causes it to fall to its initial level by negative feedback mechanism, the membrane regains its original permeability and is ready to conduct another impulse. During this time the nerve fiber is unresponsive to a depolarizing current and, therefore, cannot conduct an impulse. This interval is very brief (2 millisecond) and the nerve fibers can carry very fast frequency of impulses. The absolute refractory period is followed by a recovery of excitability 71 during which time the threshold of the nerve is higher than normal, and so only stimuli of very great strength can evoke a propagated impulse, which is it self smaller and slower. There exists self regenerative sodium conductance of the stimulated membrane, which changes the initial depolarization to the all or none full-sized action potential that is propagated without loss of amplitude along the entire length of the fiber. Unmyelinated fibers are thin, slow conducting nerves often called "C" fibers on the basis of their diameter of less than 1 micron. The addition of myelin sheath allows an enormous increase in conduction velocity with a relatively small increase in fiber diameter. Saltatory conduction Inefficient electrical characteristic are compensated by the wrapping of the axon in concentric layers of myelin, which acts as insulating sheath that increases the resistance and greatly lowers the capacitance of the surface and by nodes of Ranvier at 1 mm distance that lifts the attenuated signals( see fig. Shows propagation of Nerve impulse in myelinated nerve fibers 74 The stimulus A stimulus is any change that can alter the energy state of a tissue sufficiently to depolarize the membrane. A nerve can be stimulated by mechanical, thermal, chemical, osmotic or electrical stimulation. These various stimuli are converted or transduced by the nerve to an electrical response, i. Excitability Excitability may be defined as the ability of a cell to respond to a stimulus with an action potential. Excitability and parameters of the stimulus A stimulus must fulfill to evoke response. Neuromuscular junction / synapse The neuromuscular junction is the specialized region of contact between nerve and muscle. Each skeletal muscle fiber receives only one of the many terminal branches of the nerve fiber. All movements are composites of contraction of muscle unit, the motor neuron, its axon, and all the muscle fibers it innervates. The resulting contraction of each muscle fiber of the motor unit is all –or- nothing. Increase in the strength of muscle contractions are obtained through the recruitment of greater number of motor units. Motor unit: is the motor nerve and all the muscle(s) innervated by the nerve Functional anatomy of neuromuscular Junction Presynaptic Structure The axon terminals in knobs on the membrane surface do not fuse with it. There are active zones of the presynaptic membrane, where transmitter 75 release occurs. The presynaptic membranes have selective ionic gates, voltage gated ++ Ca channels The synaptic Cleft: The cleft is a gap of about 40 mm separating the axon terminal and the muscle membrane. Postsynaptic Structure At the junction area, there is an enlargement of the sarcoplasm of the muscle fiber, known as the end plate. The postsynaptic membrane is both structurally and physiologically different from the rest of the muscle membrane.


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