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Her hemoglobin level is 7 g/dl generic finpecia 1mg otc, and she has shortness of breath and fatigue order 1 mg finpecia with amex. She denies any obvious source of blood loss buy finpecia 1 mg, such as menorrhagia or rectal bleeding buy finpecia 1 mg with mastercard. Before you leave the room to write your orders discount finpecia 1mg visa, you explain the risks and benefits of blood product transfusion. Which of the following statements about blood components is true? Whole blood transfusion would be preferable to red cell transfusion in this patient B. Leukocyte reduction reduces febrile transfusion reactions C. Cryoprecipitate consists of albumin and platelets D. Single-donor platelet transfusions carry a higher risk of blood-borne infection than platelet concentrates Key Concept/Objective: To understand the components of whole blood Except for some autologous blood programs that use whole blood rather than packed red cells, use of whole blood has now been almost completely supplanted by therapy employ- ing specific blood components. To prevent transfusion reactions or to delay alloimmu- nization, red cells are further processed by leukocyte reduction or washing to remove plasma proteins. Current filter technology reduces white cell counts to less than 5 × 106 cells per unit, a concentration that is sufficient to reduce febrile transfusion reactions and 5 HEMATOLOGY 23 delay alloimmunization and platelet refractoriness. With single-donor platelet therapy, there is a reduction in the risk of blood-borne infection and antigen exposure, because the product is from one donor rather than four to six; disadvantages are a longer collection time, greater cost, and often limited supply. Fresh frozen plasma (FFP) that is frozen with- in 8 hours of collection contains all the procoagulants at normal plasma concentrations. Cryoprecipitate consists of the cryoproteins recovered from FFP when it is rapidly frozen and then allowed to thaw at 2° to 6° C. These cryoproteins include fibrinogen, factor VIII, von Willebrand factor, factor XIII, and fibronectin. A 58-year-old man with acute myelogenous leukemia received chemotherapy 10 days ago. He now pres- ents to the emergency department with severe fatigue and shortness of breath. Results of complete blood count are as follows: white cell count, 800/µl; hemoglobin level, 7. Which of the following statements regarding indications for transfusion of blood products is true? In patients with acute blood loss, the first treatment goal is transfusion of packed red blood cells B. Platelet transfusions are contraindicated in autoimmune thrombocy- topenia C. The prevalence of bleeding increases significantly below a threshold of about 10,000 platelets/µl in otherwise asymptomatic patients D. In chronically anemic patients, red cell 2,3-diphosphoglycerate pro- duction is decreased to maximize the red blood cells’ oxygen affinity Key Concept/Objective: To know the indications for transfusion of blood products The decision whether to use red cells depends on the etiology and duration of the anemia, the rate of change of the anemia, and assessment of the patient’s ability to compensate for the diminished capacity to carry oxygen that results from the decrease in red cell mass. Restoration of intravascular volume, usually with crystalloid, ensures adequate perfusion of peripheral tissue and is the first treatment goal for a patient with acute blood loss. In general, the decision to transfuse platelets rests on the answers to two questions: (1) Is the thrombocytopenia the result of underproduction or increased consumption of platelets? Thrombocytopenia can result from decreased production caused by marrow hypoplasia or from increased consumption caused by conditions such as idiopathic thrombocytopenic purpura (ITP). Studies have shown that the prevalence of bleeding increases significantly below a threshold of about 10,000 platelets/µl in otherwise asymptomatic patients. Transfusion is appropriate in a bleeding patient whose platelet count is adequate but whose platelets are nonfunctional as a result of medications such as aspirin or nonsteroidal anti-inflammatory drugs or as a result of bypass surgery. Proper investigation of the causes of thrombocytopenia will iden- tify clinical situations in which platelets should be withheld because they contribute to evolution of the illness. These disorders include thrombotic microangiopathies such as thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome, and the HELLP syn- drome (hemolysis, elevated liver enzymes, and a low platelet count). Platelet transfusions will not help patients with autoimmune thrombocytopenia (e.

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This Q of the PFJ discount finpecia 1mg line, than to the actual graft harvest- angle increases when there is hip anteversion discount 1mg finpecia free shipping, ing effective 1 mg finpecia. Tridimensional CT scan showing the diminution of the patellofemoral contact area in PFM buy 1mg finpecia free shipping. An excessive pronation leads to44 generic finpecia 1mg mastercard,60 (1) an increase in the Q angle; (2) an anterior dis- placement of the proximal tibia, with the conse- quent flexion of the knee and because of this an increase in the PFJR force; (3) an increase of the impact forces that reach the knee joint, due to the calcaneal eversion, which is, therefore, unable to increase its eversion (we must remember that calcaneal eversion constitutes an important shock-absorbing mechanism, to lessen the impact forces when jumping or running); and (4) an internal tibial rotation that affects the PFJ dynamics. Leg length discrepancy is one of the causes of pronated feet. It would be logical to correct it as part of the conservative treatment, although up to now there are no studies relating to leg length discrepancy and anterior knee pain. These factors could explain the frequent asso- Figure 4. PFJR force (FPFJR) in a knee with patellar tendon adhesions to the proximal tibial surface. Therefore, knee mechanics,Am J Sports Med1998; 26: 715–724. This association between hip anteversion, in-facing angle is also increased in certain attitudes prac- patellae, external tibial torsion, pronated feet ticed in sports (Figure 4. As the knee starts (positive Helbing sign [medial arching of the to flex, the tibia derotates, diminishing the Q Achilles tendon]), and bayonet sign is known in angle and the valgus vector. From 20° or 30° of the orthopedic bibliography as “miserable flexion, resistance to lateral subluxation is malalignment syndrome. Out of all these factors, pronated foot is one of Relation Between Morphotype and the most important in the etiology of patellofemoral pain60 (Table 4. Pronated foot Extensor Mechanism Pathology should not be confused with flat foot, as it is not Lower limb possibilities of malalignment in the different spatial planes are: (1) frontal plane (genu valgum and genu varum); (2) sagittal plane (genu recurvatum and genu flexum); and (3) Table 4. Etiology of pronation transversal plane (femoral and tibial torsion). Intrinsic causes Valgus knees (genu valgum) show the tibial Forefoot varus Hindfoot varus tuberosity further lateral than normal and fol- Tibial varus lowing this an increase in the Q angle that will be Extrinsic causes even bigger when there is external tibial tor- sion. Biomechanical Bases for Anterior Knee Pain and Patellar Instability in the Young Patient 63 Figure 4. The Q angle imposes a valgus vector in the last degrees of extension (a). In many sport positions knee valgus is strained, which increases the Q angle and the valgus vector (b). This type of knee, more frequent in Genu flexum is also associated with anterior women, shows a higher incidence of recurrent knee pain as it increases the PFJR force. Excessive wear of the lateral heel area of the shoe means a heel varus and is very frequent(a). When this is very severe it may contribute to the production of lateral knee pain. In this situation treatment with orthopedic insoles is fundamental (b). These alterations could be partially related to patellofemoral pathology. This leads to an excess of the tension on the medial Swimming as an Example of Pain patellofemoral ligament (MPFL) as well as of the stresses on the lateral side of the patella and the by Overuse trochlea. Initially this induces pain and later it To highlight the importance of excessive valgus provokes instability, chondromalacia and and PFJR force in the pathology we are dealing patellofemoral osteoarthrosis. Quadriceps exercises this competitive sport there is no weight-bearing occasionally provoke an overcharge of the knee or contact. In freestyle, backstroke, and butter- joint that increases the pain and the inhibition fly there is a knee flexion associated with every of the muscle, in the end paradoxically causing kick, with a repetitive contraction of the quadri- greater atrophy. In addition to this, when in the contact pressure of the PFJ with femur pushing against the wall when starting and turn- rotation. Another sure at the lateral side of the PFJ and a decrease cause for this pain could be an increase in valgus of both at the medial side of the same joint. Flexion of the knee in freestyle (a), back- stroke (b), and butterfly (c).

The dorsal horn is The anterior spinal artery discount finpecia 1mg free shipping, the main blood supply to the likewise large cheap finpecia 1mg line, because of the amount of afferents coming spinal cord finpecia 1 mg with amex, comes from branches from each of the verte- from the skin of the fingers and hand discount 1mg finpecia with visa. The posterior spinal arteries sup- • All the ascending tracts are present and are ply the dorsal horn and the dorsal columns order finpecia 1 mg fast delivery. CLINICAL ASPECT • All the descending tracts are fully represented, as many of the fibers will terminate in the cer- The blood supply to the spinal cord was reviewed with vical region of the spinal cord. In fact, some of Figure 2B; it is known that this blood supply is marginal, them do not descend to lower levels. The learner is encouraged to work out the clinical symptomatology fol- lowing lesions of the spinal cord at various levels. James Papez initiated the lim- we use the term psychological reaction. In addition, many of these alterations are conscious and involve association areas. Paul MacLean has postulated that there are in fact three are sometimes able to describe and verbalize their reac- separable “brains” that have evolved. Both cortical and subcortical (reptilian) brain has the capacity to look after the basic life areas (e. In higher species, including mammals, forebrain hypothalamus controls the autonomic changes, along with structures have evolved that relate to the external world brainstem nuclei, and also the activity of the pituitary (e. These are adaptive, allowing for a mod- gland underlying the endocrine responses. Therefore, we can finally arrive at a definition of the MacLean has suggested that the limbic system arises limbic system as an interrelated group of cortical and subcor- in early mammals to link these two brain functions; tical (noncortical) structures that are involved in the regulation according to this scheme, the limbic system relates the of the internal or emotional state, with the accompanying reptilian brain, which monitors the internal milieu, with physiological, behavioral, and psychological responses. Many now view the NEURAL STRUCTURES limbic system from this perspective. In neuroanatomical terms, the limbic system is thought to include cortical and noncortical (subcortical, diencephalic, DEFINITION and brainstem) structures. The following is a listing of the Most of us are quite aware or have a general sense of what structures: we mean when we use the term “emotion” or feelings, yet it is somewhat difficult to explain or define precisely. Cortical: Thus, emotions involve: • Core: The hippocampal formation, which consists of three subparts (which are “bur- • Physiological changes: This includes basic ied” in the medial temporal lobe in humans), drives such as thirst, sexual behavior, and appe- parahippocampal gyrus, cingulate gyrus tite. These changes are often manifested as alter- • Extended: Parts of the prefrontal and orb- ations of the autonomic nervous system or the itofrontal cortex (the limbic forebrain) endocrine system. Noncortical: that is, performs some type of motor activity, for • Forebrain: example fighting, fleeing, displaying anger, mat- • Core: Amygdala, septal region, ventral ing; in humans, this may include facial expression. Memory systems are usually grouped into two types: bic midbrain), and medulla All of these structures are collectively called the limbic sys- • Memory for skills and procedures called pro- tem. The particular role of the olfactory system and its con- cedural memory nections will be discussed in the context of the limbic system. It information and relate the external and internal worlds — is critical to understand that this initial step is an absolute the hippocampal formation, the parahippocampal gyrus, prerequisite to the formation of any new memory trace. Once encoded by the hippocampal formation, the memory trace is then transferred to other parts of the brain for short- • The hippocampal formation is an older cortical and long-term storage. The limbic system seems not to be region that is involved with integrating infor- involved in the storage and retrieval of long term memories. This idea proposes that to undo or unlock the fixed nections with many cortical (particularly sensory) behavioral patterns of the old reptilian brain, some part of areas and is probably the source of the most sig- the brain must be assigned the function of “recording” that nificant afferents to the hippocampal information. In order to change a response, the • The amygdala is in part a subcortical nucleus organism needs to “remember” what happened the last time involved with internal (visceral afferent) infor- when faced with a similar situation, hence the development mation, as well as receiving sensory input about of memory functions of the brain in association with the olfaction (our sense of smell). The availability of stored • The hypothalamus oversees autonomic physio- memories makes it possible for mammals to override or logical and hormonal regulation. Therefore, (the amygdala, in part, via the hypothalamus), and both we have suggested that the “F” mnemonic — forgetting — are involved along with other structures in generating may be applicable for this “memory” function. OTHER “LIMBIC” FUNCTIONS LIMBIC CONNECTIONS In summary, the limbic system — both cortical and noncor- The limbic system has internal circuits connecting the key tical components — includes a set of “F” functions: feeding structures; these link the hippocampal formation, the para- (and other basic drives), fornication (reproduction), fighting hippocampal gyrus, the amygdala, and the hypothalamus, and fleeing (behavioral), feeling (psychological), and “for- as well as other structures of the limbic system. Only some of these pathways will responding to the vocalizations of the “pups” in rodents, be presented. The best known of these functionally (and for cats, and other animals; a mother responds to the unique historical reasons) is the Papez circuit (discussed with Fig- tone of her own baby’s crying. Additional pathways that connect the limbic to be the area of the brain involved in this activity. This structures to the remainder of the nervous system and notion of rearing and “family” would add another “F” to through which the limbic system influences the activity of our list of limbic functions.

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