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By: Roohollah R. Sharifi, MD, FACS

  • Professor of Urology and Surgery, University of Illinois at Chicago College of Medicine
  • Section Chief of Urology, Jesse Brown Veterans Administration Hospital, Chicago, Illinois

The menisci (plural of meniscus) are a pair of C-shaped fibrocartilages which lie between the femur and tibia in each knee asthma allergy immunology best 10mg singulair, extending peripherally along each medial and lateral aspect of the knee asthmatic bronchitis 33 buy singulair 4mg visa. Each meniscus has a flat underside to asthma cure purchase singulair 4 mg line match the smooth top of the tibial surface, and a concave superior shape to provide congruency with the convex femoral condyle. Anterior and posterior horns from each meniscus then attach to the tibia to hold them in place. This organic matter is primarily a fibrous collagen matrix consisting of type I collagen, fibrochondrocytes, proteoglycans, and a small amount of dry noncollagenous matter. Most studies indicate that the menisci transmit about 50% of the load at the knee, while the remaining 50% is borne directly by the articular cartilage and surfaces. Tears are the most common form of meniscal injury, and are generally classified by appearance into four categories: longitudinal tears (also referred to as bucket handle tears), radial tears, horizontal tears, and oblique tears. Longitudinal (bucket handle) tears - vertical tear around the long axis of the meniscus often with displacement of the inner margin (bucket handle). Horizontal tears - tears that are in the same horizontal axis as the meniscus tissue. Oblique tears - full thickness tears running obliquely from the inner edge of the meniscus out into the body of the meniscus. Essentially every study shows that articular cartilage pressures escalate when the menisci are removed. Figure 7-6: Increase in joint contact stress versus percent Ahmed and Burke showed of meniscus removed. As the percentage of meniscus a 40% increase in the removed during surgery increases, joint contract stress increases exponentially. Thus arthroscopic meniscectomy contact stress while Baratz dramatically increases the incidence of future degenerative and associates found a 235% knee arthritis. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. Tibiofemoral contact mechanics after serial medial meniscectomies in the human cadaveric knee. A reasonable average estimate taken from the available literature indicates that total meniscectomy results in a two- to three-fold (200-300%) increase in contact stresses. Following partial or total meniscectomy, articular degenerative changes have been described, including the formation of osteophytic ridges, generalized flattening of the femoral articular surface, and narrowing of the joint space. Degenerative changes appear first in the tibiofemoral contact areas, with those areas formerly covered by the meniscus involved later. It occurs early Figure 7-7: Ultrasound of knee showing medial meniscus in 40% of individuals, but is defect. Besides the proliferative arthritis that results, a concomitant decrease in the ability to function follows. Let no one, especially someone in a white coat with an arthroscope, do anything to your menisci. This may produce articular cartilage breakdown, which leads to thinning of the articular cartilage. As a result of this, increased pressure on the underlying tibia bone is observed, which leads to more pressure on the ligaments. Ligament tears, worsened instability, and chronic pain often result, which Pain Levels Before & After Prolotherapy further weaken the joint. Patients were interviewed an average of 18 months after their last Prolotherapy treatment. The improvements with Prolotherapy met the expectations of the patients in over 96% of the knees to the point where surgery was not needed. Prolotherapy improved knee pain and function regardless of the type or location of the meniscal tear or degeneration. The improvements were so overwhelmingly positive that Hackett-Hemwall Prolotherapy should be considered as a first-line treatment for pain and disability caused by meniscal tears and degeneration. As we age, these bones wear, and their degeneration has been clearly associated with meniscus degeneration. As we stated earlier, the meniscus is the cartilage padding that acts as a shock absorber. When damaged the protective cartilage that covers the thigh and shin bones is now stressed.

Differential Diagnosis the word concussion is to asthma treatment trials singulair 10mg fast delivery be avoided because of lack of agreement in definition of term asthma symptoms hindi generic singulair 10mg without a prescription. Confusion with possible accompanying depression asthma symptoms fever buy singulair 5 mg with visa, post-traumatic stress disorder, and other accompanying or complicating psychiatric organic brain dysfunction disorders is to be avoided. In the presence of focal neurologic findings, convulsions, or organic brain syndrome, it is necessary to rule out subdural hematoma and other space-occupying lesions. The spouse or family is much more likely to be aware of the irritability of the victim. The Syndrome of "Jabs and Jolts" (V-11) ("Ice-Pick Pain" [Raskin]; "Multiple Jabs" [Mathew]; "Idiopathic Stabbing Headache" [nomenclature of the International Headache Society]) Definition Shortlasting (mostly "ultra-short") paroxysms of head pain, with varying localization, even in the same patient; most often unilateral; in one or more locations. During one period, the pain may be situated in one area, only to move to another one during another period. In the preheadache phase of chronic paroxysmal hemicrania, it may appear on the side opposite that of the pain. Page 85 Main Features Prevalence: probably common, since it appears both on its own and in many combinations. Frequently associated with various types of unilateral headache, such as chronic paroxysmal hemicrania, cluster headache, migraine, temporal arteritis (giant cell arteritis), hemicrania continua, and probably also tension headache. Since several of the headache forms with which it is combined have a clear female preponderance (see above), it is likely that within some of them there is a female preponderance also of Jabs and Jolts. Pain Quality: Sharp, shortlasting, superficial, neuralgiform ("knifelike") pain, superimposed upon the preexisting pain if it occurs in conjunction with another specific headache. Under such circumstances jabs and jolts seem to increase at the time of the symptomatic episodes and in the related areas. The Syndrome of Jabs and Jolts also seems to be a headache per se, unassociated with any of the above-mentioned headaches. Time Pattern: Extremely unpredictable paroxysms from a temporal point of view, but may appear in bouts (cycles); even within such periods, irregular appearance, from less than once per day to multiple times per hour; the jabs usually appear together with the associated headache. Each paroxysm may last 1-2 seconds, but may occasionally last up to 1 minute (partly as lingering pain after the severe pain). Underlying mechanism: occasionally perhaps, mechanical irritation from enlarged lymph nodes. Associated Symptoms and Signs Few, if any, except for those of accompanying conditions. In some patients there is a good, incomplete effect from indomethacin (150 mg a day). The erratic spontaneous course of this headache makes the assessment of drug therapy a most difficult task. Usual Course Sporadic paroxysms, or bouts with accumulation of paroxysms, the bouts being of extremely varying duration, from less than one per day to many daily for months. Social and Physical Disability In periods with accumulated jabs, the patient may be transitorily handicapped. Essential Features Ultrashort paroxysms in the cephalic area, in multiple sites, with no fixed location, and with very varying frequency, often occurring in bouts. Occurs sporadically or in conjunction with other headaches, such as chronic paroxysmal hemicrania, migraine, etc. Temporal Arteritis (Giant Cell Arteritis) (V-12) Definition Unilateral or bilateral headache, mainly continuous with aching or throbbing pain, sometimes very intense, usually in the elderly, with signs of temporal artery involvement-and occasionally more extensive cranial arterial involvement. Commonly associated with muscular aching ("polymyalgia rheumatica") and systemic disturbances like malaise, low-grade fever, and weight loss. Site the pain is maximal in the temporal area on one or both sides, from which it may spread to neighboring areas. Pain Quality: varying severity from dull aching to intense pain, more or less continuous, at times pulsating headache. Precipitating Factors Mastication may produce an effect of intermittent claudication.

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You helped me to asthma symptoms from anxiety purchase 10 mg singulair otc see the big picture and this process would never have been the same without you asthma symptoms lasting 4 weeks buy singulair 5mg with mastercard. Experimental pelvic pain impairs the performance during the active straight leg raise test and causes excessive muscle stabilization asthma treatment levels singulair 5 mg for sale. This, more than anything indicates that our understanding of the mechanisms underlying the pain condition is either lacking or the ability to convey the knowledge gained from clinical or experimental pain studies to clinical practice needs improvement. In pregnancy, this is evident in a recent review (Pennick and Liddle 2013) which demonstrated that the effect sizes from various treatment options are small and that no single intervention is superior to the other. This may relate to the multifactorial nature of pain in general which clinicians and researchers are encouraged to acknowledge in the current guidelines for pelvic girdle (Vleeming et al. One of the key factors in understanding pain is the mechanism underlying it, its evolvement in the transition from acute into chronic pain and the contribution of peripheral and facilitated central mechanisms in the maintenance of the given pain condition. Such an understanding can to some extent be gained by investigating how healthy subjects react to a short duration of experimental ~7~ pain. In an experimental setting, pain is often induced using exogenous (chemical, mechanical and electrical) methods which have proven useful in investigating the sensory (Sinclair et al. In pregnancy, widespread pain sensitivity has been demonstrated, becoming less prominent towards the end of third trimester which is considered to be related with an increased activity of descending pain inhibiting mechanisms (Draisci et al. However, it still is unclear what mechanisms underlie pregnancy-related pain and increased pain sensitivity, why it seems to naturally accompany pregnancy and how/if changes in sensitivity of the peripheral and central nervous system are a part of this process. In this model, quantitative sensory testing was used to assess the pain intensity, pain referral patterns and pain sensitivity in local and referred pain areas. Furthermore, these findings were compared with the outcome of manual clinical tests to see if pain per se could change their outcome. Although it is outside the scope of the current findings to comment on clinical intervention, it is clearly demonstrated that the pain and pain sensitivity are important factors to consider in clinical decision making. An improved understanding of this complex interaction may result in improved mechanisms-based treatment and management strategies with hopefully improved outcomes for this clinical population. This can be related with many factors such as the complexity of diagnosing the problem, a large overlap in gross-anatomy and neuro-anatomy and close proximity of structures capable of producing pain in the area. The distinction between low back pain and pain from the posterior aspect of the pelvic girdle is not clear with different terminology being used when investigating the painful condition in pregnant and non-pregnant populations. This is perhaps best reflected in the two separate guidelines that exist for pelvic girdle pain (Vleeming et al. In the current thesis, the term lumbopelvic pain is chosen as it is not the intention to make a clear distinction between pain originating in the pelvic girdle or low back (Wu et al. However, 7-10% of women suffer from varying degrees of pain and disability beyond the time when all pregnancy related changes are expected have returned to normal (Wu et al. It is possible that prolonged pain and suffering after delivery is related with increased sensitivity of pain mechanisms which may be affected by several factors (see section 2. The sacroiliac joint has often been implicated as the origin of pain in this area in both pregnant and non-pregnant populations (Maigne and Planchon, 2005, Katz et al. In pregnancy, the clinical history usually involves an insidious onset of symptoms where levels of pain and disability do not seem to be related with gestation week (Gutke et al. Pregnant women often complain of symptoms in the low back and pelvic girdle (Bastiaanssen et al. Additionally, women often report of multiple pain areas during pregnancy (Brown and Johnston, 2013, Borg-Stein et al. The sensitivity of the tests however, is lower and the outcome of a single test is for that reason of little value. The battery of tests in the current study consisted of six tests all together (Fig. Instead, they lay on the side and a force was applied in a posterior-anterior direction on the center of the sacrum, causing an anterior shearing force of the sacrum against both ilia.

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Many such patients will not have a repeat reaction asthmatic bronchitis 21 cheap 10 mg singulair, and if a repeat reaction occurs asthma unusual symptoms generic 5mg singulair, it will most likely be of the same severity as the previous breakthrough reaction (e asthma symptoms buy singulair 5 mg overnight delivery. The greatest risk of corticosteroid premedication to patient health is probably the delay that it causes in the performance of an imaging study (which can delay disease diagnosis, increase cost, and, in 25 inpatients, expose patients to the additional risk of hospital-acquired infections for longer periods of time). While transient hyperglycemia can occur from three doses of corticosteroids, it is usually mild and is rarely clinically significant. Other complications from a short burst of corticosteroids, such as exacerbation of infection and peptic ulcer disease, steroid psychosis, and tumor lysis syndromes, have been reported, but are very rare. Such injury may occur whether or not the contrast medium is determined to have caused the deterioration in renal function. Catheter angiography may be associated with additional risks to the patient that could also affect renal function, including catheter manipulation in the abdominal aorta (i. These include diabetes mellitus, dehydration, cardiovascular disease, diuretic use, advanced age, multiple myeloma, hypertension, and hyperuricemia. Although patients with end-stage renal disease who are on chronic hemodialysis could experience additional renal function compromise (resulting in a further decrease in any remaining urine output that might be helpful for managing electrolyte balance), such a risk is theoretical. Many nephrologists agree to inject these patients with intravascular contrast media if a contrastenhanced study is necessary. There is also a possibility that such patients, if their fluid status is brittle, could develop fluid overload as a result of the administration of even a relatively small volume of hyperosmolal26 ity contrast media. Because iodinated contrast media have no significant toxicity if retained in the body after injection, there is no requirement that chronic dialysis be timed to occur either immediately before or immediately after contrast media administration. When iodinated contrast media administration is deemed necessary in high-risk patients, the lowest possible dose needed to perform a diagnostic study should be used. Some suggested volume expansion protocols have included administration of volumes of 100 mL/h for 6 to 12 hours before contrast administration and continued for 4 to 12 hours after contrast administration. Administration of N-acetylcysteine has been widely studied but is of dubious value. PracticalSafetyApplicationsinRadiology Metformin Metformin-containing drugs are prescribed as oral agents of choice for treating many patients with diabetes mellitus. Metformin is contraindicated in patients with severe renal dysfunction because a very small percentage of these patients develop lactic acidosis, leading to a reported 50% mortality rate. In the latter instances, the drug should be withheld for 48 hours after contrast media administration and only reinstituted if the renal function is reassessed and found to be acceptable. Iodinated Contrast Media in Pregnancy It is known that iodinated contrast media crosses the placenta, but there is no evidence that maternal exposure to intravascular iodinated contrast media is harmful to the fetus. Specifically, there is no evidence that fetal exposure to iodinated contrast media increases mutagenesis or cancer risk or affects renal function. This represents less than 1% of the recommended infant dose of iodinated contrast media that could be used for a contrast-enhanced imaging study on that infant. There is no evidence that this tiny amount of absorbed iodinated contrast media has any adverse effect on the infant. Although it is generally accepted that no precautions need to be taken, it is recommended that a lactating mother be informed that studies assessing the risks to an infant are limited. If concerned, the mother can abstain from breastfeeding for 12 to 24 hours after a 27 contrast-enhanced study is performed and pump and discard breast milk that is produced during this time. While extravasations are more likely to occur when poor catheter insertion technique is utilized, they can be encountered even when proper technique is employed. Patients are believed to be at increased risk for extravasation when distal access sites are used (such as the hand, wrist, foot, and ankle) rather than the antecubital fossa, when utilized indwelling lines have been in place for more than 24 hours (in which case some degree of phlebitis may be present), and when there are multiple punctures into the same vein. Certain risk factors are believed to be associated with an increased volume of extravasated contrast, including inability of the patient to communicate (as is the case with infants, young children, and patients with altered consciousness), severe illness, and debilitation. Immediately after extravasation of contrast media occurs, most patients complain of swelling or tightness and/or stinging or burning pain at the site of extravasation. In the remaining 2% of injuries, some patient morbidity develops because contrast media can damage adjacent tissue, likely due to a combination of direct toxic effects and its hyperosmolality.

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In the immunization of adolescents and young adults against measles asthma yeast purchase 4mg singulair overnight delivery, asking women if they are pregnant asthmatic bronchitis treatment guidelines purchase 4mg singulair mastercard, excluding women who are asthma urgent care buy discount singulair 10mg, and explaining the theoretical risks to others are recommended precautions. These decisions usually are made at the local level with input from the health department and are based on the local epidemiology of the outbreak. People receiving their second dose, as well as may be readmitted immediately to the school or child care facility. Serologic testing is not recommended during an outbreak before immunization, because rapid immunization is required to halt disease transmission. Health care personnel without evidence of immunity who have been exposed should be relieved of should be relieved of patient contact until 4 days after rash develops. In fulminant cases, purpura, limb ischemia, coagulopathy, pulmonary edema, shock (characterized by tachycardia, tachypnea, oliguria, and poor peripheral perfusion, with confusion and hypotension), coma, and death can ensue within hours despite appropriate therapy. Signs and symptoms of meningococcal meningitis are indistinguishable from those associated with acute meningitis caused by other meningeal pathogens (eg, Streptococcus pneumoniae). In severe and fatal cases of meningococcal meningitis, raised intracranial pressure is a predominant presenting feature. Less common manifestations of meningococcal infection include conjunctivitis, septic arthritis, and chronic meningococcemia. Invasive infections can be complicated by arthritis, myocarditis, pericarditis, and endophthalmitis. A self-limiting postinfectious meningococcal infection and most commonly presents as fever and arthritis or vasculitis. This novel vaccine is highly effective and has the potential to end epidemic meningitis as a public health concern in sub-Saharan Africa. Prolonged outbreaks of serogroup B meninseveral clusters of serogroup B meningococcal disease have occurred on college campuses disease in parts of Africa but is rare on other continents. During the past 60 years, the annual incidence of meningococcal disease in the have occurred over multiple years. Distribution of meningococcal serogroups in the United States has shifted in the past 2 decades. Serogroups B, C, and Y each account for approximately 30% of reported cases, but serogroup distribution varies by age, location, and time. Approximately three quarters of cases among adolescents and young adults are caused by serogroups C, Y, younger than 60 months, 60% of cases are caused by serogroup B and therefore are not preventable with vaccines licensed in the United States for those ages. Disease rates are highest in children 2 years or younger; the peak incidence occurs in infants. Patients with persistent complement tomic or functional asplenia are at increased risk of invasive and recurrent meningococcal disease. Patients should be considered capable of transmitting the organism for up to 24 hours after initiation of effective antimicrobial treatment. However, most cases of meningococcal disease are sporadic, with fewer than 5% associated with outbreaks. However, susceptibility testing is not Resistance of N meningitidis to penicillin is rare in the United States. If chloramphenicol is not available, meropenem can be used, although the rate of cross-reactivity in penicillin-allergic adults is 2% to 3%. For travelers from areas where penicillin resistance has been reported, cefotaxime, ceftriaxone, or chloramphenicol is recommended. Chemoprophylaxis is warranted for people who have been exposed directly to a brushes or eating utensils, as well as for child care and preschool contacts during the 7 days before onset of disease in the index case. People who frequently slept in the same dwelling as the infected person within this period also should receive chemoprophylaxis. If antimicrobial agents other than ceftriaxone or cefotaxime (each of which will eradicate nasopharyngeal carriage) are used for treatment of invasive meningococcal disease, the child should receive chemoprophylaxis before hospital discharge to eradicate nasopharyngeal carriage of N meningitidis. Because secondary cases can occur several weeks or more after onset of disease in the index case, meningococcal vaccine is an adjunct to chemoprophylaxis when an outbreak is caused by a serogroup prevented by a meningococcal vaccine. In the United States, 4 meningococcal vaccines are licensed for for people 10 through 25 years of age against serogroup B. Recommendations for use of these new meningococcal serogroup B vaccines are under consideration by the American Academy of Pediatrics. This includes people with persistent complement component because of a serogroup B meningococcal disease outbreak.

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