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By D. Dargoth. Mount Ida College. 2018.

The coil is adapted to the lesion size and MRI does not always reflect tumoral status (percentage of location discount allegra 180mg online, a cutaneous mark may help allegra 120 mg without a prescription. SE T1 and T2 buy generic allegra 180mg on line, necrotic tumor after chemotherapy) order allegra 180 mg visa, which is obtained by STIR sequences are the most informative allegra 120 mg without prescription, whereas gradi- pathological analysis of the specimen. Fat saturation after gadolinium improves the contrast and should be performed in all cas- Soft-Tissue Tumors es. It may also help during follow-up to demon- Soft tissue tumors are frequent in children, and are most- strate residual tumor or local recurrences. Malignant tumors are rare, often misdiagnosed spectroscopy have been used recently but are still being at the beginning and inadequately treated by surgery. Diagnosis relies on pathology with immunohistochemical There is no specificity and malignant lesions may ap- analysis. Enzinger and Weiss classification (simplified) Benign Malignant Fibrous tissues Fibroma, fibromatosis fibrous histiocytoma, Congenital infantile fibrosarcoma, myofibro- xanthogranuloma blastic tumors, malignant histiocytofibroma Fatty tissues Lipoma, lipoblastoma liposarcoma Muscular tissues Leiomyoma Leiomyosarcoma, rhabdomyosarcoma, alveolar Rhabdomyoma RMS, embryonal RMS, undifferentiated RMS Vascular masses Infantile hemangioma, vascular malformation, Angiosarcoma, malignant hemangiopericytoma, lymphangioma Kaposi Nervous tumors Neurofibroma, plexiform neurofibroma, Malignant tumors of peripheral nerves schwanoma, melanotic progonoma, granular (MPNST) cell tumor PNET Synovial tumors Giant cell tenosynovial tumor Synovialosarcoma, malignant giant cell tenosynovial tumor Extra-osseous bone and Ossifying myositis, extraskeletal chondroma, Chondrosarcoma, osteosarcoma cartilaginous tumors Germinal tumors Mature teratoma Malignant germ cell tumor Unclassable Pilomatrixoma, myxoma Alveolar sarcoma, rhabdoid tumor Metastasis Neuroblastoma, leukemia, malignant melanoma Pseudo-tumors Abscess, hematoma, , synovial cyst, popliteal cyst, meningocele, granuloma RMS, rhabdomyosarcoma; MPNST, malignant peripheral nerve sheath tumor; PNET, primary neuro-echodermal tumor 184 A. Geoffray CT indications are now limited to very specific situa- gests malignancy. Total absence of flux suggests a be- tions, such as demonstrating calcifications in cases of nign lesion. In this situation, diagnosis re- On MRI, there are no specific morphological or signal lies more on imaging than on the pathologic appearance, criteria, but some are suggestive of malignancy, such as a which may be misleading. The other indications for CT size >5 or 6 cm, absence of hyposignal on T2, inhomo- are thoracic or abdominal parietal lesions, where artifacts geneous appearance on T1, peripheral enhancement, and are significant on MRI. Sharp mar- The indications for PET scan have not been estab- gins or peritumoral edema are not reliable criteria. After clinical and imaging evaluation, a decision of As for bone tumors, imaging must take the following follow up only may be made if suspicion of a benign le- into account: sion is high. Tissue characteristics: fluid seen in pseudotumoral le- of the tumor is known. Hyposignal T2 treatment planning of primary malignant bone tumors in chil- area suggests a benign lesion, such as fibrous tumor, dren. Vascularization: multiple vessels with signal void on Radiol Clin North Am 39(4):673-699 MR suggest infantile hemangiomas. On US, precise De Schepper AM, De Beuckeleer L, Vandevenne J, Somville J (2000) Magnetic resonance imaging of soft tissue tumors. Eur criteria are mandatory: more than 5 vessels per cm2, Radiol 10:213-223 velocity over 2 kHz; these allow differentiation from Enzinger FM, Weiss SW (1995) Soft tissue tumors. Dubois J, Garel L (1999) Imaging and therapeutic approach of he- However, it is not always possible to recognize a ma- mangiomas and vascular malformations in the pediatric age group. On US, structure or homogeneity is non Shapeero LG, Vanel D, Verstraete KL, Bloem JL (2000) Fast mag- specific. A vascularization pattern on power Doppler netic resonance imaging with histologic correlation. Robben Department of Radiology, University Hospital Maastricht, AZ, Maastricht, The Netherlands Introduction Cellulitis The purpose of this article is to emphasize the role of Cellulitis is defined as an infection of the skin and sub- imaging in the diagnosis of various diseases in childhood, cutaneous tissues, with a predilection for the extremities including cellulitis, subcutaneous abscess, necrotizing in children. Staphylococcus aureus and Streptococcus fasciitis, pyomyositis, infectious bursitis and arthritis, os- pyogenes account for the majority of the infections. Patients present with soft-tis- techniques, such as ultrasonography (US), computed to- sue swelling, erythema and fever. The US appearance resembles ede- tious and non-infectious inflammatory disease. Selection ma of the subcutaneous fat, showing swelling, in- of the optimal techniques for each individual patient is creased echogenicity of the subcutaneous fat with de- essential, and factors such as cost, radiation dose and creased acoustic transmission, blurring of tissue planes, need for sedation should all be considered. US is an im- progressing to hypoechoic strands between hyperechoic portant initial modality for evaluation of musculoskeletal fatty lobules (Fig. This appearance is non-specific infections in children because it is rapid, non-ionizing, and cannot be distinguished from non-infectious caus- and very sensitive for (infectious) fluid collections and es of soft-tissue edema. Moreover, the images are not degraded by color or power Doppler US suggests an infectious metallic- or motion artefacts (as with CT and MRI). US should be combined with radiography examination shows only cellulitis, but the symptoms because the two imaging techniques are complimentary. Moreover, cellulitis, especially in the vicinity of bone, Scintigraphy (three-phase bone scan with technetium- 99m) has a high sensitivity for bone disease but a low specificty. Combining bone scintigraphy with gallium-67 and indium-111 can improve diagnostic performance. MRI and CT are not screening methods but are very useful in detailing osseous and soft-tissue changes.

He com- plains of disturbance in his sleep patterns (Theresa occasionally wan- ders at night and has to be assisted to the bathroom) generic allegra 120 mg, decreased appetite allegra 180 mg on line, and a feeling of hopelessness discount allegra 120 mg. What assistance can you offer Thomas to help him cope with his wife’s advancing disability? Education about multiple sclerosis and personalized information about his wife d discount allegra 180mg on-line. Encouragement to continue to cope with the current situation 110 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM 4 buy 120 mg allegra with mastercard. What nursing interventions might improve the patient’s sympto- matic problems? All of the above Case Study 10 Gerald is a forty-two-year-old man with a ten-year history of multiple sclerosis. He served in the Navy prior to his marriage and then became a security guard at a local company. He has brainstem symptoms (tremor, atax- ia, nystagmus) and is no longer able to work. He has been hospitalized three times during the past five years for paranoid behaviors. Following his most recent hospitaliza- tion, he promised that he would remove the guns from his home. He has been tested for cognitive impairment (memory, judgment, and learning have been affected) and has been counseled by a neuropsy- chologist until his insurance ceased covering for care. He has become increasingly abusive to his wife and family as his condition has progressed. He threatens his wife and children with both physical abuse and with his guns. He is intermittently depressed and exhibits paranoid behaviors (his wife is having an affair, his daughter should have been an abortion). Recently, his wife has been participating in coun- seling; the patient refuses to do so. She has returned to work since finances are a problem in light of the needs of the growing children. The children are having problems in school; they are responsible for the patient’s care when they return home in the afternoons. Should the patient agree to hospitalization, what discharge planning would be helpful for this family? What other nursing interventions would be helpful upon the patient’s discharge? Advising the family to consider long-term placement if this situation continues to worsen c. Ensuring that the home environment is safe for the patient and family d. All of the above 112 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM Answers to Case Study Questions Case Study 1 Case Study 7 1. Which of the following statements about the possible cause(s) of MS is incorrect? Abnormal autoimmune response to myelin develops after exposure to some environmental agent in genetically predisposed individuals b. Combined effects of the autoimmune response cause the demyelination, axonal damage, and scarring seen in patients with MS 2. How many exacerbations, with neurologic symptoms referable to lesions in the white matter of the CNS, must a patient experience before a definite diagnosis of MS can be made? On onset, MS follows a relapsing-remitting pattern in approximately what percentage of patients? Continuing care needs of a patient with relapsing-remitting MS do not include: a. Ensuring adequate access to medications and adaptive equipment 113 114 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM b. Sustaining care for patients with advanced MS may include all except which of the following? Recommending installation of adaptive hand controls on the patient’s automobile d.

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The pressure in the inferior vena cava and right atrium falls as a result of the loss of the placental circulation allegra 180 mg without prescription. Circulatory System © The McGraw−Hill Anatomy cheap allegra 180 mg amex, Sixth Edition Body Companies generic 120mg allegra visa, 2001 582 Unit 6 Maintenance of the Body TABLE 16 discount allegra 120mg on-line. Because the walls of tissues and absorb fats from the gastrointestinal tract order allegra 120 mg on line. It also is lymphatic capillaries are composed of endothelial cells with part of the body’s defense system against disease. Once fluid Objective 23 Describe the pattern of lymph flow from the enters the lymphatic capillaries, it is referred to as lymph (limf). Objective 24 Describe the general location, histological From merging lymphatic capillaries, the lymph is carried structure, and functions of the lymph nodes. The walls of Objective 25 Describe the location and functions of the lymph ducts are much like those of veins. The pressure that keeps the lymph moving comes The lymphatic system is closely related to the circulatory system, from the massaging action produced by skeletal muscle contrac- both structurally and functionally (fig. A network of lym- tions and intestinal movements, and from peristaltic contrac- phatic vessels drains excess interstitial fluid (the approximate tions of some lymphatic vessels. The valves keep the lymph 15% that has not been returned directly to the capillaries) and moving in one direction. Additionally, the lymphatic the two principal vessels: the thoracic duct and the right lym- system functions in fat absorption and in the body’s defense phatic duct (fig. The larger thoracic duct drains lymph from against microorganisms and other foreign substances. The main trunk of this vessel ascends along the spinal column and drains into the left sub- • It transports excess interstitial (tissue) fluid, which was ini- clavian vein. In the abdominal area, there is a saclike enlargement tially formed as a blood filtrate, back to the blood. The smaller right lymphatic duct drains lymphatic vessels from the • Its cells (called lymphocytes), located in lymphatic tissues, right upper extremity, right thoracic region, and right side of the help provide immunological defenses against disease- head and neck. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 16 Circulatory System 583 FIGURE 16. Interstitial (tissue) fluid is an extract of blood plasma formed at the pulmonary and systemic capillary networks. Lymph is the interstitial fluid that enters the lymphatic capillaries to be trans- ported by lymphatic vessels to the venous bloodstream. The reticular tissue contains phagocytic cells that help purify the fluid. Lymph nodes are small bean-shaped bodies enclosed within fibrous connective tissue capsules. Afferent lymphatic vessels carry lymph into the node, where it is circulated through the sinuses, a series of irregular channels. Lymph leaves the node through the efferent lymphatic vessel, which emerges from the hilum—a depression on the concave side of the node. Lymphatic nodules within the node are the sites of lymphocyte production, and are thus important in the develop- ment of an immune response. Lymph nodes usually occur in clusters in specific regions of the body (see fig. Some of the principal groups of lymph nodes are the popliteal (not illustrated) and inguinal nodes of FIGURE 16. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 584 Unit 6 Maintenance of the Body Adenoid Left subclavian vein Tonsil Thymus Cervical lymph nodes Right lymphatic duct Right subclavian vein Axillary lymph Thoracic nodes duct Bone marrow Spleen Lymphatics of mammary gland Mesenteric Cisterna chyli lymph nodes Lymph node Inguinal lymph nodes FIGURE 16. Lymph from the upper right extremity, the right side of the head and neck, and the right thoracic region drains through the right lymphatic duct into the right subclavian vein. Lymph from the remainder of the body drains through the thoracic duct into the left subclavian vein. The sub- mucosa of the small intestine contains numerous scattered lym- In addition to the lymph nodes just described, the tonsils, spleen, phocytes and lymphatic nodules, and larger clusters of lymphatic and thymus are lymphoid organs. The tonsils form a protective tissue called mesenteric (Peyer’s) patches. Migrating cancer cells (metastases) are especially dangerous if they enter the lymphatic system, which can disperse them The tonsils, of which there are three pairs, combat infection of widely. On entering the lymph nodes, the cancer cells can multiply the ear, nose, and throat regions.

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Some synthetic CCK-B receptor antagonists are chemically similar to the benzodiazepine anxiolytics generic 120mg allegra with visa. Again allegra 120mg discount, the clinical role of CCK manipulation in anxiety remains to be resolved generic allegra 120 mg amex. NEUROPEPTIDE Y Neuropeptide Y (NPY) is a large 36 amino-acid peptide found in large amounts in the brain buy generic allegra 180mg online. Although the central administration of NPY in animals causes a number of biological effects which range from control of CRF discount 180mg allegra with visa, increased food intake, anxiolysis, changes in memory and circadian rhythms, the five receptors for the peptide and the lack of any really selective tools for the Y1, 2, 4, 5 and 6 receptors (what happened to the Y3 site! The marked vasoconstrictor actions of the peptide in the periphery will mean that systemic therapy will require receptor subtype selective agents. VASOPRESSIN Vasopressin is closely related to oxytocin and both peptides are cyclic in that they contain a disulphide bridge. Although much is known about the peripheral actions of the peptides the extent of our current knowledge of their possible CNS function is that vasopressin appears to act as a cognitive enhancer and has positive effects on learning processes in animals. SOMATOSTATIN Somatostatin exists in two forms, a 14 and a 28 amino-acid form called SRIF-14 and SRIF-28, respectively. Both are widely distributed in the CNS and the peptide produces inhibitory effects on neurons via G-protein-coupled opening of potassium channels. The original receptor division was twofold with a SRIF-1 and -2 receptor division but it is now clear that what are now known as sst2, 3 and 4 subtypes make up the former receptor while the sst1 and 4 receptors are the original SRIF-2 site. Few antagonists exist at present but the distribution of the peptide with high levels in cortex, hippocampus, amyglada and spinal cord may give some clues to potential functions of the peptide. SRIF given directly to the spinal cord is antinociceptive which would be expected from an inhibitory peptide, although some studies suggest toxic rather than physiological effects of the peptide. By contrast, the peptide appears to promote convulsions Ð here its role may be through disinhibition. A well-established central role in the control of growth hormone release has given rise to hopes of treatment of agromegaly and in other contexts, motor actions and increases in sleep times in animals suggest a number of roles of this peptide. NEUROTENSIN Neurotensin is a peptide with well-established digestive functions which is also found in CNS neurons. There are two receptors (1 and 2) and a paucity of agonists apart from Table 12. The 13 amino-acid peptide has been implicated in analgesia, thermoregulation and interactions with dopamine function in the nigrostriatal and mesolimbic pathways. CGRP Calcitonin gene-related peptide (CGRP) is a product of the calcitonin gene with a distinct mRNA which is formed from alternative splicing in a tissue-specific manner. Thus CGRP is the main product in the CNS whereas calcitonin is found in the thyroid. The peptide is excitatory but whether there is a single receptor or two remains a point of dispute. There are large amounts of CGRP and substance P in fine sensory nerves and the two peptides are released into the periphery by antidromic stimulation where they contribute to the wheal and flare via vasodilatation through complex interactions. There is evidence that this effect of CGRP is via a potentiation of the vascular effects of SP while at the central terminals of sensory nerves the effects of substance P are enhanced by competing with it for a common peptidase so that the metabolism of SP is reduced. Hence there is interest in the potential of CGRP antagonists as therapies for inflammation and headache, although there are no useful compounds of this class at present. Other actions of CGRP have been reported such as altered food intake and thermoregulatory effects. GALANIN Galanin is a 29 amino-acid peptide, one amino acid longer in humans than in rats, which acts on three known receptors, GalR1±3, all of which are G-protein-linked receptors, in common with all peptides. There is a lack of any antagonist and apart from a truncated version of galanin having some GalR2 selectivity, no means of separation of the three receptors. However, the consequences of receptor activation are clear in that the GalR1 and 3 receptors are inhibitory and the GalR2 excitatory, although some mixed effects have been reported with the latter. The 1 and 3 receptors open potassium channels whereas the GalR2 receptor mobilises internal calcium, possibly via IP3 mechanisms. The distribution of the 1 and 2 receptors differs, with the former being enriched in hippocampus, spinal cord and peripheral nerves whereas GalR2 has a wider distribution.

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