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In a posterior dislocation aygestin 5mg with mastercard, the sultant shortening and external rotation of the lower ex- hip is displaced posteriorly and often slightly superiorly; tremity order aygestin 5 mg with visa. Although these are readily diagnosed by conven- the thigh is held in adduction safe aygestin 5mg. Much less common are an- tional imaging aygestin 5mg for sale, at times there is an apparent radiolucen- terior dislocations of the hip 5mg aygestin visa, in which the femoral head cy in the femoral neck, suggesting that the fracture is is seen in a medial and inferior position; the thigh is held pathologic. The area of lucency is due to rotation of the fracture frag- Knee ments. When femoral-neck fractures are impacted, diag- nostic problems increase. The position of the hip is usu- Routine imaging includes at least two views, AP and lat- ally in valgus and these fractures may be recognized as eral. Tangential views of the patella and tunnel views may bands of density extending across the femoral neck or by be used to supplement these, particularly when joint ef- a “squared-off ” contour to the head-neck junction along fusions are demonstrable. Patients with im- be helpful in detecting fractures of the tibial plateau. If a lipohemarthrosis is demonstrable on hori- tertrochanteric region; the lesser trochanter may represent zon-beam images, this is presumptive evidence for an in- a separate bony fragment in these cases. In these cases, CT is often the most tures of the greater trochanter should raise the possibility expeditious way to demonstrate these fractures. In patients with CT may not be able to detect other intra-articular abnor- conventional images indicating an avulsion of the greater malities. For this reason, MRI may be even more useful trochanter, MRI should be preformed in order to evaluate as it can detect ligamentous injuries, meniscal tears and the intertrochanteric region for incomplete fracture. Osteochondral injuries of the femoral condyles displacement of the medial fragment. Avulsion fractures at process of the calcaneus occur and must be distinguished the insertion of the posterior cruciate ligament are often from normal variants in this location. Knowledge of the in- missed on conventional imaging and diagnosis often fol- sertion point of the posterior cruciate ligament in this lo- lows MRI performed for persistent ankle pain. This fracture, which can be usually readily demonstrable on tangential views of the demonstrated on conventional imaging, has an extremely calcaneus or on CT. When this fracture is identified, MRI will clearly the calcaneus and navicular. In adolescent athletes, epiphyseal separations are cult to see on conventional imaging and may require CT more common than ligamentous injuries. Asymmetry in the width of the growth plate or small fracture fragments on The Forefoot the metaphyseal side of the growth plate should be suffi- cient to establish the diagnosis in most cases. MR may be The Lisfranc fracture-dislocation of the tarso-metatarsal a valuable technique when the nature of the injury is in joints is a frequent injury. This injury is easily over- question and also allows evaluation of ligamentous struc- looked, and a careful examination of the relationships of tures about the knee. Ankle and Hindfoot In the forefoot, stress and other fractures of the metatarsals are not uncommon. Avulsions of the base of Conventional imaging of the ankle should include AP, in- the fifth metatarsal, at the point of insertion of the per- ternal oblique (“mortise”) and lateral images. Fractures oneus brevis muscle, should be distinguished from of the malleoli are common ,and careful examination for “dancer’s fracture” or Jones fracture. These occur near the presence of posterior malleolar fracture is necessary the base of the fifth metatarsal, approximately 2. If a tal to the base, in a relatively avascular area of the shift of the talus in the ankle mortise has occurred and no metatarsal and may go on to non-union. Fractures of the lateral malleolar fracture is demonstrated, examination of phalanges in the foot are quite common. It is important the entire length of the fibula is necessary to demonstrate to evaluate all images so that these are not overlooked. Isolated Fractures of the sesamoids may also occur; most com- fractures of the posterior malleolus do occur and may on- monly at the first metatarsal phalangeal joint.

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In turn purchase aygestin 5mg otc, activated endothelial cells injury buy aygestin 5 mg on-line, components of the hemostatic system are activated order 5mg aygestin visa. They may be activated on exposure to for- forming a bridge between cell surface receptors and colla- eign surfaces during bleeding cheap 5mg aygestin free shipping, or by torn tissue at the site of gen in the subendothelial matrix buy aygestin 5 mg low price. The protein thrombin, injury, or by products released from the interior of dam- which is generated by the plasma coagulation cascade, is a aged cells. Hemostasis can be viewed as four separate but potent activator of platelet adherence and secretion. Rup- interrelated events: tured cells at the site of tissue injury release adenosine • Compression and vasoconstriction, which act immedi- diphosphate (ADP), which causes platelets to aggregate at ately to stop the flow of blood the damaged site. These aggregates effectively stop the • Formation of a platelet plug flow of blood from the ruptured vessels. The fibrin network traps red cells, leuko- exerted by the tissue around the injured area, and vasocon- cytes, platelets, and serum at sites of vascular damage, striction. The degree of compression varies in different tis- thereby forming a blood clot. The stable, fibrin-based sues; for example, bleeding below the eye is not readily de- blood clot eventually replaces the unstable platelet ag- terred because the skin in this area is easily distensible. Fibrin is Back-pressure increases as blood which leaks out of the dis- an insoluble polymer of proteolytic products of the rupted capillaries accumulates. Fibrin molecules are cleaved uterus after childbirth, contraction of underlying muscles from fibrinogen by thrombin, which is generated in compresses blood vessels supplying the tissue and mini- plasma during clotting. Damaged cells at the site of tissue injury mation, thrombin cleaves four small peptides (fib- release potent substances that directly cause blood vessels rinopeptides) from each molecule of fibrinogen. The fib- to constrict, including serotonin, thromboxane A2, epi- rinogen molecule devoid of these fibrinopeptides is nephrine, and fibrinopeptide B. The fibrin monomers sponta- neously assemble into ordered fibrous arrays of fibrin, resulting in an insoluble matrix of fibrous strands. At this Platelets Form a Hemostatic Plug stage, the clot is held together by noncovalent forces. First, they form plasma enzyme, fibrin stabilizing factor (Factor XIII), multicellular aggregates linked by protein strands at sites of catalyzes the formation of covalent bonds between CHAPTER 11 Blood Components, Immunity, and Hemostasis 207 strands of polymerized fibrin, stabilizing and tightening the blood clot. Blood clotting is mediated by the sequential activation of a series of coagulation factors, proteins synthesized in the liver that circulate in the plasma in an inactive state. They are referred to by number (designated by a Roman numeral) in a sequence based on the order of the discovery of each factor. The plasma coagulation factors and their common names are listed in Table 11. The sequential activation of a series of inactive mole- cules resulting in a biological response is called a metabolic cascade. The sequential activation of coagulation factors resulting in the conversion of fibrinogen to fibrin (and, hence, clotting) is called the coagulation cascade. The de- ficiency or deletion of any one factor of the cascade has se- vere consequences. Individuals deficient in factor VIII (an- tihemophilic factor), for example, display prolonged bleeding time on tissue injury, as a result of delayed clot- ting. Those who lack factor VIII have hemophilia, a condi- tion resulting in severe coagulation defects. Two separate coagulation cascades result in blood clotting in different circumstances. The two systems are the intrinsic coagulation pathway and the extrinsic co- agulation pathway (Fig. The ex- trinsic pathway is initiated by tissue factor (fac- pathway, all the factors required for coagulation are pres- 2 tor III) released from damaged cells. For initiation of the extrinsic path- tor III converts factor VII to factor VIIa, which then forms a way, a factor extrinsic to blood but released from injured complex with factor III and Ca2. This complex converts factor X tissue, called tissue thromboplastin or tissue factor (fac- to factor Xa. In the intrinsic system, factor XII is first converted to tor III), is required.

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Most individuals initially expe- cause complications can significantly rience a feeling of vulnerability and a shat- influence individuals’ medical prognosis tering of the magical belief that they are and functional capacity (Dolder buy aygestin 5mg online, Lacro order 5 mg aygestin, immune from illness discount aygestin 5 mg on-line, injury order aygestin 5 mg fast delivery, or even Leckband 5mg aygestin fast delivery, & Jeste, 2003; Schmaling, Afari, death. With this realization, they may lose & Blume, 2000; Vergouwen, Bakker, their sense of security and cohesiveness. Katon, Verheij, & Koerselman, 2003; Life may seem a maze of inconveniences, Zygmunt, Olfson, Boyer, & Mechanic, hazards, and restrictions. The best rehabilitation plan is of lit- to recommendations may be an attempt tle value if individuals do not follow the to exert self-determination, to regain a treatments designed to control their sense of autonomy and control, and to symptoms or disease or to prevent com- claim some mastery over their individual plications or progression of the disease destiny. In other instances, resistance to (Kovac, Patel, Peterson, & Kimmel, 2002; treatment recommendations may be a Loghman-Adham, 2003). Although individuals who purposely Nonadherence can also be a reflection behave in a way that makes their condi- of an individual’s feelings about his or her tion worse seem irrational, there are a life circumstances. For some individuals, number of explanations for nonadherent having a chronic illness or disability is not 18 CHAPTER 1 PSYCHOSOCIAL AND FUNCTIONAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY a positive role; for others, it may be far decrease income. The economic conse- preferable to the social role they held pre- quences of chronic illness or disability viously. If an wish to be independent and the wish to individual is receiving disability benefits remain dependent. Chronic illness or dis- and has little opportunity for satisfactory ability can be a means of legitimizing employment, he or she may not follow dependency, as well as a means of in- recommendations that would increase his creasing the amount of attention re- or her capacity to return to work and ceived. Motivation to retain the sick life is a relative concept, uniquely defined role is at times greater than the motivation by each individual. As a result, ulti- mendations result in pain, discomfort, or mate rehabilitation is hampered. If health scribed recommendations may not be per- and well-being are perceived as rewards for ceived as worth the psychological, social, a life well lived, illness or disability may or physical cost. Treatment can some- be viewed as punishment for real or imag- times, but not always, be adjusted to make ined actions of the past. Adherence to adhering to recommendations more palat- medical advice may be perceived as inter- able. Individuals’ right to self-determina- ference with a punishment believed to be tion must be carefully balanced with the deserved. In other instances, individuals assurance that the choice of nonadher- may feel guilty because they believe that ence is based on information and full the illness or disability is a direct result of understanding of the consequences. Some individuals readily adjust to the Guilt or shame at being different may also challenges, limitations, and associated be- hinder adherence to treatment recom- havioral changes necessitated by chronic mendations. Many individuals, attempt to hide their condition from oth- however, actively sabotage treatment and ers and, thus, fail to follow recommenda- recommendations, to their own detri- tions that they fear may call attention to ment. Many occupations offer lack of motivation, or failure to follow rec- fringe benefits, such as paid sick days or ommendations, it is important to identi- even time off with pay in which to seek fy the barriers that prohibit adherence and medical care, but other occupations pro- to recognize that such reactions may indi- vide no such benefits. In the latter in- cate difficulty in accepting the condition stances, days taken off from work because or adapting recommendations to their of illness or medical appointments can own unique way of life. Stages of Adaptation and Adjustment 19 PATIENT (CLIENT AND FAMILY) ticipate in some previously performed EDUCATION activity. Regardless of the nature of the loss, a variety of reactions may take place Although medical care, support, and while individuals attempt to make neces- auxiliary services are important aspects of sary adaptations and changes. The shock of diagnosis and its chronic disease or disability requires con- consequent implications may have a siderable individual and family effort. As the reality of the situation be- ed to carry out treatments in their home comes clear, they may experience a sense rather than depend on medical personnel of hopelessness and despair, mourning for in health care settings. Not individuals go through a period of mourn- only must they understand how to inte- ing and bereavement similar to that expe- grate regimens into daily routines and rienced when a loved one is lost. As indi- and prevent further disability or health viduals begin to appraise their condition problems (Falvo, 2004). Because of increas- realistically, examine the limitations that ing public awareness of the need for indi- it imposes, and adjust to the associated viduals to accept this greater responsibility losses, they may gradually seek alterna- and self-determination, a number of pro- tives and adaptations to become integrat- grams and counseling services have been ed into a broader world. As individuals accept their con- dition, they attain their maximal func- A host of personal, social, and environ- tional capacity. The amount of time that mental experiences, demands, supports individuals need to reach acceptance is and resources, and coping strategies inter- dependent on personality, the reaction of act to influence adaptation outcomes family and significant others, life circum- (Livneh, 2001). The process of adjustment stances, available resources, and the types includes a search for meaning in the expe- of challenges that confront them.

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The role of the general medical ed antibodies predict multiple sclerosis? How can we pre- Multiple sclerosis and epilepsy: Vocational aspects vent Lyme disease? Psychosocial in amyotrophic lateral sclerosis: A population- adaptation to chronic illness and disability cheap 5 mg aygestin fast delivery. Psychosocial adaptation to spinal England Journal of Medicine aygestin 5mg on-line, 346(6) cheap aygestin 5 mg online, 390 safe aygestin 5 mg. A multi- Multiple sclerosis: Etiological mechanisms and generational family with multiple sclerosis buy generic aygestin 5mg line. Identifying the unmet independent living Journal of Medicine, 347(8), 1445–1447. American Journal of Respiratory Critical gression in multiple sclerosis. Association of sleep-disordered breathing, sleep References 121 apnea, and hypertension in a large community- Salcido, R. Topics in Geriatric Rehabilitation, 15(3), the American Medical Association, 238, 1829–1836. Sleep-disordered breathing and cardiovascular dis- ease: Cross-sectional results of the Sleep Heart Phillips, P. Mortality of sleep apnea patients treated by nasal continuous positive airway pressure reg- Roessler, R. European employees with spinal cord injuries: A critical Respiratory Journal, 15, 326–331. This page intentionally left blank C HAPTER 4 Conditions of the Eye and Blindness NORMAL STRUCTURE AND ing the eyeball is the choroid coat, which FUNCTION OF THE EYE contains most of the blood vessels that nourish the eye. The eyeballs are spherical organs The colored part of the eye is called the encased in the orbital cavities of the skull. At the center of the iris is a round Muscles located on the top, bottom, and opening called the pupil, which admits side of each eye enable it to rotate in dif- light to the inner part of the eye. Through fre- Smooth muscle fibers on either side of the quent blinking, the eyelid helps keep the pupil cause it to contract or dilate, there- eye moist, preventing irritation. The by automatically regulating the amount of lacrimal glands, which lie in the upper out- light that enters the eye. In bright light er side of the eye behind the eyelid, secrete the pupil contracts to reduce the amount tears to keep the eyeball moist and help of light admitted. In front of the eye lies a transparent Directly behind the iris is a space called curved structure called the cornea, which the posterior chamber. Contained in the admits light and protects the inner eye posterior chamber is a structure called the from foreign particles and organisms. The vessels, it is richly supplied with nerve aqueous humor escapes from the posteri- cells. Connected to the cornea and com- or chamber through the pupil into a space pletely covering the eyeball except for the lying between the iris and cornea called part covered by the cornea is a fibrous the anterior chamber, which lies between membrane called the sclera. The aqueous forms the white part of the eye and has humor then drains from the eye into the primary function of supporting and lymph channels and into the venous sys- protecting the eye and maintaining eye tem through a sievelike structure called shape. Lining the exposed area of the scle- the canal of Schlemm (trabecular network), ra and inner eyelid is a sensitive mem- which is located at the junction of the iris brane called the conjunctiva. The balance between the underneath the sclera and also surround- amount of aqueous humor produced and 123 124 CHAPTER 4 CONDITIONS OF THE EYE AND BLINDNESS Muscle Chorid Retina Conjunctiva Ciliary muscle Iris Aqueous humor Fovea Cornea (Macular area) Pupil Optic nerve Lens Optic disc Vitreous Anterior chamber humor Posterior chamber Canal of Schlemm Sclera Figure 4–1 The Eye. This space is filled with a jelly- cornea and a structure located directly like, translucent substance called the behind the iris called the lens. The lens is vitreous humor, which helps to maintain a small transparent disk enclosed in a the form and shape of the eyeball. Attachments around At the very back of the eye is the inner- the circumference of the lens, called ciliary most coat of the eye, the retina. The reti- muscles, automatically contract or ex- na contains two layers, a pigmented layer pand, changing the shape of the lens from that is fixed to the choroid and an inner fat to thin or vice versa in response to the layer that contains special light-sensitive proximity or distance of an object being cells called rods and cones. The changing shape of the lens Rods are involved with detecting light permits the eye to focus for near or far and dark as well as shape and movement vision, a process called accommodation. Rods contain iary muscles relax, thinning and flatten- a derivative of vitamin A, rhodopsin, a ing the lens.

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