Y. Porgan. Institute of Paper Science and Technology.

Individuals may reject new assis- and influenza vaccines are usually recom- tive devices because they symbolize the mended cheap 200mg topamax overnight delivery. Changes in Vocational Issues in Post-Polio Syndrome orthotics or in the mode of ambulation may be required generic 200mg topamax with visa. Moving from braces or Many individuals with poliomyelitis have crutches to a wheelchair can also reduce achieved gainful employment and lived stress on joints buy 100 mg topamax fast delivery. Although its cause re- number of alterations necessary in the mains unknown order 200 mg topamax free shipping, evidence suggests that work setting 200 mg topamax free shipping. In some instances, depending both genetic and environmental factors on performance requirements, the individ- may play a role (Janson, Leone, & Freese, ual may be unable to perform all of the 2002; Nussbaum & Ellis, 2003). Thus altering job duties or retrain- son’s disease involves extensive degener- ing for other job duties may be necessary. Most of the ability to lift, reach, walk, or climb may disabling symptoms associated with be altered. Parkinson’s disease are due predominant- The symptoms of post-polio syndrome, ly to drastic reductions of dopamine lev- whether pain, weakness, or fatigue, may els in the brain. Individuals who once increased the number of diagnosed cases used crutches or braces may require a of Parkinson’s disease among younger wheelchair for ambulation. If, because of increased describe a parkinsonian syndrome in symptoms and disability, the individuals’ which individuals experience Parkinson- current mode of transportation is no like symptoms that are due to other caus- longer accessible, transportation to and es. In addition, ciated with the ingestion of certain drugs because of increased disability, individu- (prescription or illicit) or exposure to tox- als may require additional time to get ic substances, such as carbon monoxide or ready for work. Secondary parkinsonism In some instances the onset of new gained attention in the early 1980s when symptoms and increasing limitations may the “designer drug” MPTP, which mim- result in depression, which can interfere icked the action of heroin, entered the with the individual’s ability to work effec- street market. Supportive counseling may be nec- after taking the drug, suddenly developed essary to enable the individual to cope permanent signs and symptoms of severe with increasing disability. Some medications used to treat mental illness may also pro- NEUROMUSCULAR CONDITIONS duce Parkinsonlike side effects if not closely monitored. Parkinson’s Disease A variety of other conditions mimic Parkinson’s disease, causing similar symp- Parkinson’s disease is a slowly progres- toms. These symptoms are collectively sive disorder of the central nervous sys- called parkinsonism and should be distin- tem, leading to progressive impairment of guished from Parkinson’s disease. Neuromuscular Conditions 95 Manifestations of Parkinson’s Disease more deliberate as the condition progress- es. As food collects in the mouth and the The four most common symptoms of back of the throat, individuals may be Parkinson’s disease include: prone to coughing and choking episodes. Motor changes related to Parkinson’s dis- • tremor ease may cause speech changes related to • muscle rigidity incoordination and reduced movement of • akinesia (complete or partial absence the muscles that control breathing, voice, of movement, or difficulty with vol- pronunciation, and rate of speaking. Vol- untary movement, especially of the ume of speech may be decreased (hypo- extremities) phonia), and there may be no verbal inflec- • postural instability tions. Reduction in amplitude In early stages of the condition, indi- of movement may affect individuals’ abil- viduals may exhibit extreme slowness in ity to write so that their handwriting initiating or maintaining movements gradually becomes smaller and smaller (bradykinesia). Parkinson’s disease may walk with small, Tremor of a limb, usually most notice- shuffling steps and may have difficulty ris- able in one hand, is the most frequent ear- ing from a chair or bed. The difficult to initiate or to stop voluntary tremor intensifies when the hand rests in movements. While walking, for example, the lap (resting tremor) and diminishes they may experience gait hesitation and with voluntary movement. The tremor is suddenly “freeze,” taking seconds to re- not present during sleep, however. The impairment arms fail to swing with their stride when experienced with bradykinesia can inter- they are walking. The loss of postural re- fere with activities such as shaving, but- flexes makes it difficult for these individ- toning clothes, or cutting food, all of uals to maintain an upright position if they which take longer and become more diffi- are suddenly bumped, increasing the risk cult to perform as the disease progresses. To keep from falling, they may Because Parkinson’s disease affects both inadvertently quicken their steps as if to the central and autonomic nervous sys- “catch up” with their own center of grav- tems, some individuals may also experi- ity. They may blink less engage in voluntary movement, fatigue is frequently and may develop a masklike, also increased. They may develop dif- Mental and behavioral changes do not ficulty swallowing (dysphagia), which always occur as a result of Parkinson’s dis- results in saliva accumulation and drool- ease, but cognitive changes, as well as ing.

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Such a response would spare metabolic most are microbial products discount 100 mg topamax with amex, microbial toxins discount topamax 200mg visa, or whole mi- energy and might be advantageous in an environment that croorganisms cheap topamax 100mg online. The best studied of these is the lipopolysac- is not so cold that a blunted metabolic response would al- charide endotoxin of gram-negative bacteria generic topamax 200 mg on line. A thalamus (and perhaps elsewhere in the brain) to alter their lower core-to-skin conductance (i order topamax 100mg online. This effect of climatization in which a reduction in the metabolic re- endogenous pyrogens is mediated by the local synthesis and sponse to cold occurred. This increased insulation is not due to subcutaneous fat (in fact, it has been observed in release of prostaglandin E2. Aspirin and other drugs that in- very lean subjects), but apparently results from lower blood hibit the synthesis of prostaglandins also reduce fever. In general, the cold liable indicator of the presence of disease that body tem- stresses that elicit a lower shell conductance after acclima- perature is probably the most commonly measured clinical tization involve either cold water immersion or exposure to index. Many of the body’s defenses against infection and air that is chilly but not so cold as to risk freezing the vaso- cancer are elicited by a group of polypeptides called cy- constricted extremities. However, other cytokines, par- ticularly tumor necrosis factor, interleukin-6, and the in- Cold-Induced Vasodilation and the Lewis Hunting Re- terferons, are also pyrogenic in certain circumstances. As the skin is cooled below about 15 C, its blood vated body temperature enhances the development of flow begins to increase somewhat, a response called cold- these defenses. If laboratory animals are prevented from de- induced vasodilation (CIVD). This response is elicited veloping a fever during experimentally induced infection, most easily in comfortably warm subjects and in skin rich in survival rates may be dramatically reduced. The this chapter, fever specifically means an elevation in core mechanism has not been established but may involve a di- temperature a resulting from pyrogens, some authors use rect inhibitory effect of cold on the contraction of vascular the term more generally to mean any significant elevation smooth muscle or on neuromuscular transmission. After repeated cold exposure, CIVD begins Many Factors Affect Thermoregulatory Responses earlier during cold exposure, produces higher levels of and Tolerance to Heat and Cold blood flow, and takes on a rhythmic pattern of alternating vasodilation and vasoconstriction. This is called the Lewis Regular physical exercise and heat acclimatization increase hunting response because the rhythmic pattern of blood heat tolerance and the sensitivity of the sweating response. This re- Aging has the opposite effect; in healthy 65-year-old men, sponse is often well developed in workers whose hands are the sensitivity of the sweating response is half of that in 25- CHAPTER 29 The Regulation of Body Temperature 547 year-old men. Heat exhaustion, also called heat col- ously those used for their anticholinergic effects, such as lapse, is probably the most common heat disorder, and rep- atropine and scopolamine. In addition, some drugs used for resents a failure of cardiovascular homeostasis in a hot en- other purposes, such as glutethimide (a sleep-inducing vironment. Collapse may occur either at rest or during drug), tricyclic antidepressants, phenothiazines (tranquil- exercise, and may be preceded by weakness or faintness, izers and antipsychotic drugs), and antihistamines, also confusion, anxiety, ataxia, vertigo, headache, and nausea or have some anticholinergic action. The patient has dilated pupils and usually sweats others have been associated with heatstroke. As in heat syncope, reduced diastolic filling of heart failure and certain skin diseases (e. Although blood pressure may be low patients with these diseases, heat exposure and especially during the acute phase of heat exhaustion, the baroreflex exercise in the heat may raise body temperature to danger- responses are usually sufficient to maintain consciousness ous levels. Lesions that affect the thermoregulatory struc- and may be manifested in nausea, vomiting, pallor, cool or tures in the brainstem can also alter thermoregulation. Patients with heat ex- Such lesions can produce hypothermia (abnormally low haustion usually respond well to rest in a cool environment core temperature) if they impair heat-conserving re- and oral fluid replacement. However, hyperthermia (abnormally high core intravenous replacement of fluid and salt may be required. However, heat exhaustion accompanied circadian rhythm of core temperature. Certain drugs, such as barbiturates, alcohol, and phe- Therefore, patients should be actively cooled if rectal tem- nothiazines, and certain diseases, such as hypothyroidism, perature is 40. Hypovolemia cially in debilitated patients, may be accompanied by hy- contributes if the patient is dehydrated, but heat exhaustion pothermia, instead of the usual febrile response to infec- often occurs without significant dehydration. This is reversed shortly before the maintenance of blood pres- failing appears to be due to an impaired ability to conserve sure fails. The most severe and dangerous heat disorder is characterized by high core temperature and the develop- Heat Stress Causes or Aggravates ment of serious neurological disturbances with a loss of Several Disorders consciousness and, frequently, convulsions. In the classical The harmful effects of heat stress are exerted through car- form, the primary factor is environmental heat stress that diovascular strain, fluid and electrolyte loss and, especially overwhelms an impaired thermoregulatory system, and in heatstroke, tissue injury whose mechanism is uncertain. In exer- In a patient suspected of having hyperthermia secondary to tional heatstroke, the primary factor is high metabolic heat heat stress, temperature should be measured in the rectum, production. Patients with exertional heatstroke tend to be since hyperventilation may render oral temperature spuri- younger and more physically fit (typically, soldiers and ath- ously low.

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Histology © The McGraw−Hill Anatomy topamax 200 mg with amex, Sixth Edition of the Body Companies generic topamax 100mg with visa, 2001 84 Unit 3 Microscopic Structure of the Body Larynx Trachea Bronchiole Lung Secondary bronchi (b) (b) Cilia Goblet cell Bronchus Nucleus (a) Basement membrane Connective tissue (c) FIGURE 4 cheap 200 mg topamax with mastercard. Uterine tube Ovary Uterus Urinary bladder Cervix Urethra Rectum Vagina Anus (b) (a) Stratified squamous epithelium (c) FIGURE 4 discount 100mg topamax visa. In the moistened areas buy discount topamax 100mg on-line, such as in the vagina (a), it is nonkeratinized, whereas in the epidermis of the skin it is keratinized. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 Chapter 4 Histology 85 Parotid gland Nuclei Lumen of parotid duct Basement (b) membrane (c) Parotid duct (a) FIGURE 4. Stratified Cuboidal Epithelium As the newly produced cells grow in size, they are pushed toward Stratified cuboidal epithelium usually consists of only two or the surface, where they replace the cells that are sloughed off. This type of epithelium is Movement of the epithelial cells away from the supportive base- confined to the linings of the large ducts of sweat glands, salivary ment membrane is accompanied by the production of keratin (ker′a˘- glands, and the pancreas, where its stratification probably pro- tin) (described below), progressive dehydration, and flattening. There are two types of stratified squamous epithelial tis- sues: keratinized and nonkeratinized. Keratinized stratified squamous epithelium contains ker- atin, a protein that strengthens the tissue. Keratin makes Transitional epithelium is similar to nonkeratinized stratified the epidermis (outer layer) of the skin somewhat waterproof squamous epithelium except that the surface cells of the former and protects it from bacterial invasion. The outer layers of are large and round rather than flat, and some may have two nu- the skin are dead, but glandular secretions keep them soft clei (fig. Nonkeratinized stratified squamous epithelium lines the permit distension (stretching) of the urinary bladder as it fills oral cavity and pharynx, nasal cavity, vagina, and anal with urine. This type of epithelium, called mucosa (myoo-ko′sa˘), being rounded when the urinary bladder is empty to being some- is well adapted to withstand moderate abrasion but not what flattened as it distends with urine. The cells on the exposed surface are alive and are A summary of membranous epithelial tissue is presented in always moistened. Stratified squamous epithelium is the first line of defense against the entryof living organisms into the body. Stratification, Body Membranes rapid mitotic activity, and keratinization within the epidermis of the skin are important protective features. An acidic pH along the surfaces of Body membranes are composed of thin layers of epithelial tissue this tissue also helps to prevent disease. Body membranes cover, separate, and sup- gion is about 6, and the pH along the vaginal lining is 4 or lower. The two basic types of body membranes, mucous membranes and serous membranes, are described in detail in chapter 2 under the heading “Body keratin: Gk. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 86 Unit 3 Microscopic Structure of the Body Ureter (b) Urinary bladder (b) Lumen of urinary bladder Transitional epithelium Urethra Smooth muscle tissue (a) (c) FIGURE 4. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 Chapter 4 Histology 87 Secretion Lumen Mucus Liver Cell membrane Stomach Gallbladder Golgi complex Large intestine Small intestine Nucleus of goblet cell Rough endoplasmic reticulum Creek (a) (b) (c) FIGURE 4. Multicellular glands, as their name implies, are composed of both secretory cells and cells that form the walls of the As tissues develop in the embryo, tiny invaginations (infoldings) ducts. Multicellular glands are classified as simple or com- or evaginations (outfoldings) of membranous epithelia give rise to pound glands. The ducts of the simple glands do not specialized secretory structures called exocrine (ek′so˘-krin) glands. These glands remain connected to the epithelium by ducts, and Multicellular glands are also classified according to the their secretions pass through the ducts onto body surfaces or into shape of their secretory portion. Exocrine glands should not be confused with en- tubular glands if the secretory portion resembles a tube and docrine glands, which are ductless, and which secrete their prod- as acinar glands if the secretory portion resembles a flask. Multicellular glands with a secretory portion that resem- Exocrine glands within the skin include oil (sebaceous) glands, bles both a tube and a flask are termed tubuloacinar glands. Exocrine glands within the digestive system include the salivary and pancreatic glands. Multicellular glands are also classified according to the Exocrine glands are classified according to their structure means by which they release their product (fig. Merocrine (mer′o˘-krin) glands are those that secrete a wa- structure, there are two types of exocrine glands, unicellular and tery substance through the cell membrane of the secretory multicellular glands. Unicellular glands are single-celled glands, such as goblet glands are of this type. Apocrine (ap′o˘-krin) glands are those in which the secre- occur within most epithelial tissues. Goblet cells are found tion accumulates on the surface of the secretory cell; then, in the epithelial linings of the respiratory and digestive sys- a portion of the cell, along with the secretion, is pinched tems. The mucus secretion of these cells lubricates and pro- off to be discharged.

Acetabular screws generic 100 mg topamax visa, if used safe topamax 200mg, should (12%) and a degree of prosthetic subsidence (7%) buy topamax 200 mg visa. The lucent line has Complications of Joint Replacement a sclerotic margin and develops during the first 2 years after insertion topamax 200mg generic. A metal- joints topamax 200 mg cheap, including pain and other symptoms, for which no bone lucency may be present immediately after surgery cause may be found. In addition, not all abnormal joint replace- quential radiographs for cemented devices whereas slight ments are associated with symptoms. Overall, complica- subsidence is acceptable, and part of the design in unce- tions occur in 1-5% of total hip replacements annually. The major complications are described in the follow- ing: Knee Replacements Loosening With or Without Coexisting Infection Alignment: Obtain standing views to check alignment and compare with earlier radiographs. The infection rate is approximately 1% of total hip replacements, 2% of Total knee: The tibial articular surface should be par- total knee replacements and 3% of revision joints per an- allel to the floor in a weight-bearing position. Obviously, figures vary but at 10 years after inser- femoral component should lie in 5-7° of valgus. The tion as many as 50% of hips may appear radiographical- patellar button should be central and well embedded in ly loose, 30% requiring revision. Weissman The major plain-film findings of loosening include the 18[F]-fluorodeoxyglucose (FDG) positron emission to- presence of cement-bone lucencies and/or cement-metal mography is relatively untried, but appears to perform lucency of more than 2 mm in width. The progressive similarly to 3-phase bone scan but less well than conven- widening of an interface, especially if associated with bone tional radiographs. The presence of a joint effusion (shown on plain X-ray or ultrasound) implies a Arthrography joint that is abnormal, although a small joint effusion is usual in total knee replacements. Additional signs include The major objective of arthrography is to obtain fluid for excessive component migration or subsidence of unce- culture and sensitivity and to document intra-articular mented components, subsidence of cemented components, needle position. It is important to remember to aspirate cement or fatigue fractures of metallic components, dis- material for both aerobic and anaerobic cultures. A periosteal reaction should always be re- riostatic, aspiration prior to local anesthetic or saline in- garded as suspicious of infection, as opposed to local cor- jection is preferred. If the joint appears ‘dry’, or only a tical thickening, which represents a stress response. False-positive and false-nega- ing may be extremely difficult but features that suggest tive cultures occur, and thus synovial biopsy is preferred infection include excessive bone destruction, the radiolu- by some authors. As empha- as a therapeutic trial (does this ablate the pain of which sized, periosteal new bone formation is highly suggestive the patient complains? However, in- The sensitivity of arthrography is increased when con- fection is often low grade and associated with a non-vir- trast medium is injected under pressure (with local anes- ulent organism, and may be difficult to detect. Further Investigations Features shown on arthrography include loosening, component failure and extra-articular collections and Scintigraphy tracks. Specific signs at the acetabulum of loosening in- clude the leakage of contrast at the cement-bone/metal- Bone-seeking 99mTc compounds demonstrate abnormal up- cement interface in 90% of loose replacements and ex- take for 9-12 months post-operatively. Thereafter, increased tension of contrast into pseudo-bursae in about 56%. Abnormal activi- Femoral loosening is confirmed in about 98% by contrast ty in the blood pool or perfusion phase should suggest in- medium tracking into the cement-bone interface below fection, particularly if the abnormality is diffuse. In the late the intertrochanteric line, or in the bone-metal interface phase, the classical 3-point scan suggests varus tilt and below the intertrochanteric line. Again, a diffuse increase in activity suggests in- stemmed devices, contrast medium below the level of fection; however, the ability to separate infection from asep- mid-component is abnormal. A normal bone scan has a hip include communication with greater trochanteric bur- strong negative predictive value. However, for reasons that sae (50%), supra-acetabular collections (33%) and filling have yet to be explained, bone scans are often abnormal in of the iliopsoas bursa (17%). Lymphatic filling remains a otherwise uncomplicated total knee replacements and thus controversial finding and is probably not significant, al- have a poorer positive predictive value. It had a high neg- At the knee, contrast under the tibial tray, or the cement ative predictive value but a poor positive predictive val- interface is abnormal. Component failure, especially the ue, making a negative result more useful. The finding of a 111Indium labeled white blood cells afford increased Baker’s cyst may explain a patient’s symptoms and signs, sensitivity and specificity when used in combination with but in most cases is not relevant.

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