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This deformity has been variously de- Saunders buy 100mg vantin free shipping, Philadelphia best 200 mg vantin, pp 311-318 Hill N (1970) Fractures and dislocations of the carpus discount 200mg vantin with mastercard. It is readi- North 1:275 ly diagnosed generic 100 mg vantin, both clinically and on the lateral radiograph discount vantin 200 mg mastercard, Rawles JG (1988) Dislocations and fracture at the carpometacarpal with or without an avulsion fracture. Hand Clin 4:103 Rogers LF (2001) Radiology of skeletal trauma, 3rd Edition. Penetrating injuries Churchill Livingstone, Philadelphia, pp 813-855 Rogers LF (2001) Radiology of skeletal trauma, 3rd Edition. Churchill Livingstone, Philadelphia, pp 904-929 Penetrating injuries to the hand and wrist result from stab Wagner CJ (1959) Fracture-dislocations of the wrist. Gilula Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Another cause for diffuse swelling along one side of the wrist or finger can be tenosynovitis. This chapter will emphasize general principles when as- The evaluation of alignment (“A”) allows deviations sessing a variety of lesions of the hand and wrist. Angular deformities are proach to analyzing the wrist and hand bones will be pro- commonly seen in arthritis. Dislocations and carpal in- vided, followed by a discussion of applications of these stabilities manifest as abnormalities in alignment. Acute bone demineralization presents possible to cover all of musculoskeletal imaging and as subcortical bone loss in the metaphyseal areas and at pathology in a short article; however, some major points the ends of bones, in regions of increased vascularity of will be emphasized in each of these different areas, with bones. A typical example is the young person who has the most emphasis placed on complex carpal trauma. Diffuse even demineralization commonly develops over longer Overview of Analysis periods of time and may be seen in older people with dif- fuse osteopenia of age and also from prolonged disuse. Forrester, looking at the muscu- Focal osteopenia, especially associated with cortical loskeletal system anywhere can be evaluated by the “A, loss, should raise the question of infection or a more B, C, D, ‘S” system. Utilizing these principles the margins of these joints and bones for cartilage space will help keep one from missing major observations. Starting with “S” for soft tissues will keep one from for- “D” refers to the distribution of abnormalities. Recognizing soft-tissue most vividly exemplified by the distribution of erosions, (“S”) abnormalities will point to an area of major abnor- as may be seen distally in psoriasis and more proximally mality and should trigger a second or third look at the in rheumatoid arthritis. The soft tissues dor- lelism, (2) overlapping articular surfaces, and (3) three sally over the carpal bones are normally concave. All three can be especially applied to the the soft tissues over the dorsum of the wrist are straight carpal bones. Parallelism refers to the fact that any anatomic line volar to the distal radius suggests deep swelling when structure that normally articulates with an adjacent anatom- it is convex outward, as normally it should be straight or ic structure should show parallelism between the articular concave. Soft-tissue swelling along the radial and ul- cortices of those adjacent bones. This is exactly how jigsaw nar styloids may be seen in synovitis or trauma. If there is a piece of a jigsaw puzzle out of along the radial or ulnar side of a finger joint can indi- place, then that piece loses its parallelism to adjacent cate collateral ligament injury. Anatomically, this would cause overlapping articu- ment exist along the radial side of the index finger and lar surfaces. Therefore, the concepts of parallelism and the ulnar side of the small finger. If there is overlap ferentially around one interphalangeal or metacarpopha- of normally articulating surfaces, there should be disloca- langeal joint is highly suggestive of capsular or joint tion or subluxation at the site of those overlapping surfaces. Gilula This does not apply if one bone is foreshortened or bent, as Trauma with overlapping phalanges on a PA view of a flexed fin- ger. In that situation, one phalanx would overlap the adja- Traumatic conditions of the wrist basically can be classi- cent phalanx, but in the flexed PA position one would not fied as fractures, fracture-dislocations, and soft-tissue ab- normally see parallel articular surfaces at that joint. The third alignment concept refers to the fact that three Analysis of the carpal arcs, overlapping articular sur- carpal arcs can be drawn in any normal wrist when the wrist faces, and parallelism will help determine what exact and hand are in a neutral position, i.

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The extrapolation of fluid filtration or absorption for a Capillary Pressure Is Determined by the single capillary to fluid exchange in a whole tissue is diffi- Resistance of and Blood Pressure in Arterioles cult buy 200 mg vantin. Within organs buy 100 mg vantin fast delivery, there are regional variations in mi- and Venules crovascular pressures effective 200 mg vantin, possible filtration and absorption of fluid in vessels other than capillaries 200 mg vantin, and physiologically Capillary pressure (Pc) is not constant; it is influenced by and pathologically induced variations in the available sur- four major variables: precapillary (Rpre) and postcapillary face area for capillary exchange 200mg vantin otc. Therefore, for whole or- (Rpost) resistances and arterial (Pa) and venous (Pv) pres- gans, a measurement of total fluid movement relative to the sures. Precapillary and postcapillary resistances can be cal- mass of the tissue is used. To take into account the various culated from the pressure dissipated across the respective vascular regions divided by the total tissue blood flow (Q˙ ), hydraulic conductivities and total surface areas of all vessels involved, the volume (mL) of fluid moved per minute for a which is essentially equal for both regions: change of 1 mm Hg in capillary pressure for each 100 g of ˙ Rpre (Pa Pc)/Q (6) tissue is determined. This value is called the capillary fil- tration coefficient (CFC), although it is likely that fluid ex- ˙ Rpost (Pc Pv)/Q (7) CHAPTER 16 The Microcirculation and the Lymphatic System 271 In the majority of organ vasculatures, the precapillary re- Myogenic Vascular Regulation Allows Arterioles sistance is 3 to 6 times higher than the postcapillary resist- to Respond to Changes in Intravascular Pressure ance. Vascular smooth muscle can contract rapidly when stretched To demonstrate the effect of precapillary and postcapil- and, conversely, can reduce actively developed tension when lary resistances on capillary pressure, we use the equations passively shortened. In fact, vascular smooth muscle may be for the precapillary and postcapillary resistances to solve able to contract or relax when the load on the muscle is in- for blood flow: creased or decreased, respectively, even though the initial Q˙ (P P )/R (P P )/R (8) a c pre c v post muscle length is not substantially changed. These responses are known to persist as long as the initial stimulus is present, The two equations to the right of the flow term can be unless vasoconstriction reduces blood flow to the extent that solved for capillary pressure: tissue becomes severely hypoxic. This process, called myo- Pc (Rpost/Rpre)Pa Pv (9) genic regulation, is activated when microvascular pressure is increased or decreased. The first mechanism is a calcium ion-se- either resistance, determines the effect of arterial pressure lective channel that is opened in response to increased (Pa) on capillary pressure. The denominator plasm would activate the smooth muscle cell and result in also influences both pressure effects. Limiting calcium entry would allow calcium lary to precapillary resistance ratio of 0. The second mechanism is a nonspecific nous pressure to be reflected back to the capillaries. The cation channel that is opened in proportion to cell mem- postcapillary to precapillary resistance ratio increases during brane stretch or tension. The entry of sodium ions through the arteriolar vasodilation that accompanies increased tissue open channels would depolarize the cell and lead to the metabolism; the decreased precapillary resistance and mini- opening of voltage-activated calcium channels, followed mal change in postcapillary resistance increase capillary by contraction as calcium ions flood into the cell. Because the balance of hydrostatic and colloid os- reduced stretch or tension, the nonspecific channels would motic pressures is usually 2 to 2 mm Hg, a 10- to 15-mm close and allow hyperpolarization to occur. Hg increase in capillary pressure during maximum vasodila- Other mechanisms are likely involved in myogenic reg- tion can cause a profound increase in filtration. What is clear is that vascular smooth muscle cells creased filtration associated with microvascular dilation is depolarize as the intravascular pressure is increased and hy- usually associated with a large increase in lymph produc- perpolarize as the pressure is decreased. First, and per- Capillary Pressure Is Reduced When the haps most important, blood flow can be regulated when the Sympathetic Nervous System Increases arterial pressure is too high or too low for appropriate tis- Arteriolar Resistance sue blood flow. Second, the myogenic response helps pre- vent tissue edema when venous pressure is elevated by When sympathetic nervous system stimulation causes a more than about 5 to 10 mm Hg above the typical resting substantial increase in precapillary resistance and a propor- values. The elevation of venous pressure results in an in- tionately smaller increase in postcapillary resistance, the crease in capillary and arteriolar pressures. Myogenic arte- capillary pressure can decrease up to 15 mm Hg and, riolar constriction lowers the transmission of arterial pres- thereby, greatly increase the absorption of tissue fluid. This sure to the capillaries and small venules to minimize the risk process is important. As mentioned earlier, fluid taken from of edema, but at the expense of a decreased blood flow. The the interstitial space can compensate for vascular volume myogenic response to elevated venous pressure may be due loss during sweating, vomiting, or diarrhea. As water is lost to venous pressures transmitted backward through the cap- by any of these processes, the plasma proteins are concen- illary bed to the arterioles and, perhaps, to some type of re- trated because they are not lost. THE REGULATION OF MICROVASCULAR RESISTANCE Tissue Metabolism Influences Blood Flow The vascular smooth cells around arterioles and venules re- In all organs, an increase in metabolic rate is associated with spond to a wide variety of physical and chemical stimuli, increased blood flow and extraction of oxygen to meet the altering the diameter and resistance of the microvessels. In addition, a reduction in Here we consider the various physical and chemical con- oxygen within the blood is associated with dilation of the ditions in tissues that influence the muscle cells of the mi- arterioles and increased blood flow, assuming neural re- crovasculature. The local regulation of 272 PART IV BLOOD AND CARDIOVASCULAR PHYSIOLOGY the microvasculature in response to the metabolic needs of In contrast to venules, many arterioles have a normal-to- tissues involves many different types of cellular mecha- slightly increased periarteriolar oxygen tension during nisms, one of which is linked to oxygen availability. Therefore, as long as blood flow is allowed to in- increase in metabolic rate would decrease the tissue oxygen crease substantially, it is unlikely that oxygen availability at concentration and possibly directly signal vascular muscle the arteriolar wall is a major factor in the sustained vasodi- to relax by limiting the production of ATP for the contrac- lation that occurs during increased metabolism. Only unusually low or high oxygen ten- around large venules during skeletal muscle contractions.

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Hospitalization is frequently necessary paired cognitive functions generic vantin 100mg amex, expressing during the acute phase of mood disorders the inability to concentrate or to make de- because of the severity of the disturbance cisions purchase vantin 200mg free shipping. Other symptoms purchase vantin 200 mg otc, such as sleep that the disorder creates in interpersonal and appetite disturbances (too much or and/or occupational functioning buy vantin 200 mg lowest price. Distur- too little sleep; weight gain or weight loss) purchase vantin 200 mg amex, bances in mood can be subdivided into are called vegetative signs. The degree of impairment due to major depression varies, although social and Major Depressive Disorder occupational activities are usually affect- ed to some degree. Chronic depression Major depression is defined by de- causes marked impairment in psychosoci- pressed mood or loss of interest in nearly al function and work performance (Keller all activities (or both for at least 2 weeks) et al. With severe de- that is accompanied by three or more of pression, incapacitation can be so great the following symptoms: that individuals are unable to attend to their own daily needs, such as basic • insomnia or hypersomnia (sleeping hygiene and nutritional needs. During manic epi- Dysthymia and Cyclothymia sodes, mood becomes distinctly elevated Dysthymia is a mood disorder charac- and behavior hyperactive. Individuals in terized by symptoms similar to those expe- a manic episode appear flamboyant and rienced in major depression, but to a lesser overly enthusiastic, often engaging in degree. Although symptoms are not so excessive activity and needing little sleep. A mixed major depressive disorder and dysthymia episode is characterized by symptoms is the severity and duration of the symp- involving rapidly changing moods alter- toms. Their attention shifts rapid- acterized by symptoms similar to those of ly from one activity to another unrelated bipolar disorders, with both hypomanic activity with little provocation. Be- have grandiose delusions in which they cause symptoms are usually milder, cyclo- believe that they have special skills, knowl- thymia causes less impairment in function edge, or relationships. The distinc- occur during a manic episode and often tion between bipolar disorders and cyclo- relate to individuals’ mood or delusions. Bipolar II Disorders Bipolar II disorders are characterized by Anxiety Disorders the occurrence of at least one major de- There are several different types of anxi- pressive episode and at least one hypoman- ety disorders. The presence of the hypomanic clude not only anxiety but also increased episode distinguishes bipolar II disorders arousal and avoidance of situations that the from major depressive disorders (American individual perceives as anxiety provoking. As already described, a major depressive episode is char- Panic Disorders acterized by loss of interest in activities, sadness, and depressed mood. A hypoman- Panic disorders are types of anxiety dis- ic episode is characterized by elevated or orders in which individuals experience irritable mood over a period of time that feelings of intense fear or discomfort; they is not quite as severe as a manic state. If indi- are characterized by panic attacks, episodes Common Psychiatric Disabilities 187 in which the individual has feelings of Impairments resulting from phobias may intense anxiety or terror, accompanied by vary from mild to severe. A phobia may a sense of impending doom (American be more of a nuisance than a disability. During a the other hand, a phobia may be so dis- panic attack, individuals experience short- abling that individuals are unable to func- ness of breath, increased heart rate and tion effectively in their day-to-day activ- palpitations, sweating, and, at times, nau- ities if the phobia causes them to avoid sea or other physical discomfort. Panic particular objects or situations or causes attacks are not triggered by a certain event such anxiety that they are unable or un- and, at least initially, are unpredictable. In themselves, they may be Obsessive-Compulsive Disorder only mildly debilitating. Obsessive-compulsive disorder is a chron- Panic disorder is distinguished from gen- ic disorder that can cause significant dis- eralized anxiety in that individuals with ability if not treated, with symptoms panic disorders become preoccupied with following a waxing and waning course the physical symptoms associated with a (Maj, Sartorius, Okasha, & Zohar, 2002). Treatment Individuals with an obsessive-compulsive focuses on amelioration of symptoms disorder have recurrent obsessions (per- through medication and counseling. Agoraphobia For instance, they may have recur- Panic disorders are sometimes accompa- rent thoughts of the death of a loved one, nied by agoraphobia, the fear of being in or they may have an irresistible urge to a situation or place in which it might be perform repetitively some behavior that difficult or embarrassing to escape or in seems purposeless, such as turning a light which there may be no help available if on and off three times before retiring for the individual experiences a panic attack. Attempts by individuals to ig- Although not all individuals who have nore the compulsions only increase anx- panic attacks experience agoraphobia, iety, discomfort, and distress. Medi- venture outside their home alone, or they cation is often used in combination with may be reluctant to travel by car, bus, or cognitive-behavioral therapy, especially other common means of transportation. The term phobia refers to fear and anxi- Posttraumatic Stress Disorder ety related to specific situations, persons, or objects. Different types of phobias are cate- Posttraumatic stress disorder (PTSD) was gorized on the basis of the object of fear. PTSD is an anxiety dis- distress and impairment in social, occupa- order that develops after an individual has tional, and interpersonal functioning experienced or observed a traumatic or life- (American Psychiatric Association, 2000).

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Antibiotic prophylaxis is recommended to prevent vaginal cuff infection in all hysterectomies (3) and to prevent group B streptococcus (GBS) sepsis in the newborn (4 buy 200 mg vantin,5) generic vantin 100mg mastercard. The drug of choice for patients who have hysterectomies is a cephalosporin administered intravenously approx 30 minutes before Chapter 11 / Obstetrics and Gynecology 143 transvaginal incision generic 100mg vantin with visa. For GBS prophylaxis cheap 100mg vantin with amex, intravenous penicillin G is preferred over ampicillin for two reasons vantin 100mg without a prescription. A single loading dose of penicillin is likely as effective as two doses of ampicillin given 4 hours apart. In addition, the second most frequent cause of neonatal meningitis after GBS is Escherichia coli, which is often resistant to ampicillin. Delayed diagnosis of cancer is another major issue for this spe- cialty. The Ob/Gyn has a responsibility to inform, educate, and thus empower his or her patients about the importance of appropriate screen- ing evaluations including mammography and Pap smears. The patient’s history, including family history, is an important part of the assess- ment of risk. Trust the patient when she notes a change in status and listen to the history she relates. The responsible physician best serves the patient when he or she obtains the history in the patient’s “own words” rather than the secondhand interpretation of staff’s documen- tation. A family history of breast cancer, particularly under age 45 years, imparts increased risk to the patient. All suspicious masses should be biopsied, regardless of the mammogram interpretation. The diagnosis of cervical cancer is an important consideration in the evaluation of intravaginal bleeding. Pelvic sonography in the postmeno- pausal patient may be done to assess the thickness of the endometrium. Again, the patient’s history is often telling and may lead to a diagnosis of cancer when the appropriate evaluations are performed. The other major area of liability for this specialty is prenatal care and delivery. Prenatal diagnostic ultrasonographic evaluation of the fetus is an increasing area of litigation. It is essential that the respon- sible Ob/Gyn clarify for the patient what fetal anatomy can or cannot be seen and what diagnoses can or cannot be made. Limitations of equipment, the impact of fetal position and number, and maternal size should be emphasized. For example, only one-third of major fetal anatomic abnormalities are defined at second-trimester scans. Even when a consultant provides the interpretation of the study, the primary Ob/Gyn should review the implications of the findings with the patient and family. Additionally, genetic counseling is now so complex that only a certified counselor should do it. Fetal death imparts a responsibility on the part of the delivering phy- sician for documentation of the gross anatomy of the baby, the umbilical cord, and the placenta. Such descriptors are far more meaningful than those following examination by the pathologist hours to days later. The bulk of suits for wrongful fetal death arise when the death is unexplained, although up to 75% of fetal deaths can be under- stood after thorough gross, microscopic, and genetic analyses (6). The obstetric department should define a protocol to assess all fetal deaths. Much potential litigation can be prevented by the responsible Ob/Gyn discussing all findings with the patient and her family. This review should take place prior to discharge from the hospital and again at the postpartum visit. Under no circumstances should the patient be left with unanswered questions or concerns as these only drive attempts to get explanations from an attorney. Complications of induction of labor, although not very common, do occur and have associated risks to mother and, more commonly, baby.

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