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A 32-year-old man comes to your office for a job-related injury yasmin 3.03mg for sale. His family history is remarkable for two relatives who had “internal bleeding” in their 40s cheap yasmin 3.03mg visa. On examination, you notice multiple small telan- giectasias on his lips, skin, and oral mucosa. Chest x-ray reveals several small, perfectly round nodules in both lungs. He is likely to develop pulmonary hypertension and right heart failure B. He has an increased risk of stroke and brain abscess D. His pulmonary function tests will show significant restrictive disease E. There is no need to consider treatment if he remains asymptomatic Key Concept/Objective: To be able to recognize hereditary hemorrhagic telangiectasia and to know its consequences In this disorder, there are often numerous arteriovenous malformations (AVMs) in the lungs and elsewhere in the body. Such patients have an artificially low pulmonary resistance because a substantial fraction of blood may be shunting through the AVMs. Although the presence of AVMs generally does not lead directly to pulmonary hyper- tension, occasionally pulmonary hypertension is seen in association with AVM therapy; that is, if AVMs are resected, one can develop pulmonary hypertension because of vas- cular remodeling and an abrupt increase in resistance once the AVMs are no longer able to shunt blood. Orthopnea is actually unusual in this disorder; classically, patients have 36 BOARD REVIEW increased dyspnea when standing up, a symptom called platypnea. Pulmonary func- tion tests are generally normal except for a slightly diminished diffusing capacity of lung for carbon monoxide (DLco). The long-term risk associated with the disease is large- ly the possibility that a clot or organism could embolize through one of these malfor- mations directly to the brain. This makes treatment of asymptomatic patients contro- versial, but some favor it to prevent negative neurologic outcomes. Which of the following statements is true regarding primary pulmonary hypertension? Right heart failure is a contraindication to lung transplantation B. Calcium channel blockers are not effective therapy C. Subcutaneous epoprostenol is a safe and effective treatment D. Five-year survival is roughly similar with medical therapy and lung transplantation E. Prognosis is excellent with early treatment Key Concept/Objective: To understand the management of primary pulmonary hypertension Primary pulmonary hypertension is a challenging and rare disease with a poor prog- nosis; 5-year survival is around 50% for both medical therapy and transplantation. Right heart failure often improves with a single-lung transplant and is not considered a contraindication to transplantation. Both calcium channel blockers and epoprostenol have been shown to be effective, and both can cause significant rebound pulmonary hypertension if stopped abruptly. A 56-year-old man presents for evaluation in a primary care clinic. He has a 2-day history of right ankle swelling and pain. He reports experiencing discomfort with ambulation and when driving an automo- bile. On further questioning, he denies experiencing a recent trauma, although he does recall spraining his ankle approximately 10 years ago. His right ankle is warm to palpation and reveals an effusion. With passive range of motion of the right ankle, significant pain is elicited. Which of the following is the most appropriate step to take next in the treatment of this patient? Check the serum uric acid level; if elevated, initiate therapy with indomethacin and colchicine B. Obtain a plain radiograph of the right ankle to assess for structural damage or chondrocalcinosis C. Perform arthrocentesis of the right ankle, with analysis of the synovial fluid D.

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ANATOMY AND PHYSIOLOGY Figure 6-1 illustrates the anatomy of the heart generic 3.03mg yasmin mastercard. Heart Sounds S1 yasmin 3.03mg without prescription, the closing of the mitral valve (in the following diagram, M1) and the tricuspid (T1) valve, together known as the atrioventricular valves. S1 represents the beginning of systole; S2 represents the beginning of diastole. Sl systole S2 diastole Sl systole S2 diastole M1T1 A2P2 M1T1 A2P2 Normally, the S1 and S2 occur as single sounds. There are conditions in which these sounds may be split and occur as two sounds. There are also conditions in which there are third and fourth heart sounds that occur under both normal and pathologic conditions. In healthy young adults, a physiologic split of S2 may be detected in the second and third left interspaces during inspiration as a result of changes in the amount of blood returned to the right and left sides of the heart. During inspiration, there is an increased filling time and, therefore, increased stroke volume of the right ventricle, which can delay closure of the pul- monic valve, thus causing the second heart sound to be split. This physiologic split differs from other splits that are pathologic in origin because it occurs with inspiration and dis- appears with expiration. Pathologic split heart sounds include the following. Cardiac and Peripheral Vascular Systems 119 • Fixed splitting of S2 occurs with atrial septal defect and right ventricular failure. In addition to the first and second heart sounds, there are two additional heart sounds, S3 and S4, heard both in normal and pathologic conditions. Both S3 and S4 occur during dias- tole: an S3 is heard early in diastole right after S2, and an S4 is heard in late diastole just before S1. An S3 can occur physiologically or pathologically depending on the age and dis- ease status of the patient; an S4 usually occurs under pathological conditions. It is low pitched and is heard best at the apex or left sternal border with the bell of the stethoscope. The sound is the same as a physio- logic S3 and is heard with the patient supine or in the left lateral recumbent position. Possible causes of a left-sided S4 include hypertension, coronary artery disease, car- diomyopathy, or aortic stenosis. Possible causes of a right-sided S4 include pulmonic stenosis and pulmonary hypertension. Heard with the patient supine or in the left lateral recumbent position. Other heart sounds may occur in pathological conditions and include opening snaps and pericardial friction rubs. It is high pitched and heard best with the diaphragm of the stethoscope. The sound is a high-pitched grating, scratching sound—resulting from inflammation of the pericardial sac—that issues from the parietal and visceral surfaces of the inflamed pericardium as they rub together. The Cardiac Cycle The cardiac cycle is diagramed in Figure 6-2. Blood is returned to the right atrium via the superior and inferior vena cava, and to the left atrium via the pulmonary veins. As the blood fills the atria during early diastole, the pressure rises until it exceeds the relaxed pressure in the ventricles, at which time the mitral and tricuspid valves open and blood flows from the atria to the ventricles. At the end of diastole, atrial contraction produces a slight rise in pres- sure termed the “atrial kick. As ventricular pressure rises, it exceeds the pressure in the aorta and pulmonary artery, thus forcing the aortic and pulmonic valves to open. As the blood is ejected from the ventricles, the pressure declines until it is below that of the aorta and pulmonary artery, causing the aortic and pulmonic valves to close and thus Copyright © 2006 F. As the ventricles relax, the pressure falls below the atrial pressure, the mitral and tricuspid valves open, and the cycle begins again. HISTORY General History In many instances, the history may be more telling than the physical exam.

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Khan MA (1990) Ankylosing spondylitis and related spondyloarthropathies purchase yasmin 3.03mg visa. Khan MA (1996) Ankylosing spondylitis: Clinical fea- tures generic 3.03mg yasmin free shipping. In: Klippel JH, Dieppe PA (eds) Rheumatology, 2nd edition. AS-Ind(183-194) 5/29/02 5:57 PM Page 183 psoralen-photo-augmented ultraviolet A (PUVA) Pagets disease 99 treatment 139 pamidronate 49 psoriatic arthritis 2, 126, 132, paraplegia 89 133–5 pelvis, cancer of the 99 penicillin 62 Pepcid 41 pubic junction 10 peptides 112, 122–3 pubis 10 personalized information cards PUVA treatment 139 68–9 phenylbutazone 12, 39, 40 physical therapy, exercise and physical therapy pink eye 130 quadriplegia 68 piroxicam 39 quality of life, health-related placebo effect, nontraditional 84–5 therapy 52, 55 plantar fasciitis 22, 103 Ponstel 39 race and ethnicity Portugal 147 posture 19, 75–7, 88 radiation therapy 49–50, 89 radiology 95–6 pregnancy 79, 87 radium chloride 50 radon bath 50 Premarin 67 radon gas inhalation 49–50 Prempro 67 raloxifene 67 Prevacid 41 Ramses II 7 prevalence ranitidine 41 reactive arthritis (Reiter’s syndrome) 2, 126–28 Prilosec 41 process of AS 101–2 recreational activities 80–1 Reiter’s syndrome, reactive progesterone 67 arthritis prophylaxis 62 Relafen 39 prostatitis 131 Remicade 48, 141 proton pump inhibitors 41 remission 4, 14 . This English- language edition published by arrangement with Editorial Médica Panamericana S. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or trans- mitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case, the respective user must check its accuracy by consulting other pharmaceutical literature. Printed in Singapore (SPI/KYO) 987654321 Springer Science+Business Media springeronline. In memoriam (†) Foreword Anterior knee pain is one of the really big problems in my specialty, sports orthopaedic surgery, but also in all other types of orthopaedic surgery. Many years ago Sakkari Orava in Finland showed that among some 1311 Finnish runners, anterior knee pain was the second most common complaint. In young school girls around 15 years of age, anterior knee pain is a common complaint. In ballet classes of the same age, as much as 60-70% of the students complain of anterior knee pain. Sanchis-Alfonso to publish a book about anterior knee pain and patello-femoral insta- bility in the active young. He has been able to gather a group of extremely talented experts to help him write this book. I am particularly happy that he has devoted so much space to the non-operative treatment of anterior knee pain. During my active years as a knee surgeon, one of my worst problems was young girls referred to me for surgery of anterior knee pain. Girls that had already had 8-12 surgeries for their knee problem — surgeries that had ren- dered them more and more incapacitated after each operation. In all these cases, I referred them to our pain clinic for careful analy- sis, and pain treatment followed by physical therapy. All recovered but had been the vic- tims of lots of unnecessary knee surgery before they came to me. I am also happy that Suzanne Werner in her chapter refers to our study on the per- sonality of these anterior knee patients. She found that the patients differ from a normal control group of the same age. I think this is very important to keep in mind when you treat young patients with anterior knee pain. In my mind physical therapy should always be the first choice of treatment. Not until this treatment has completely failed and a pain clinic recommends surgery, do I think surgery should be considered. In patello-femoral instability the situation is different. When young patients suffer from frank dislocations of the patella, surgery should be considered. From my many years of treating these types of patients, I recommend that the patients undergo an arthroscopy before any attempts to treat the instability begin. The reason is that I have seen so many cases with normal X-rays that have 10-15 loose bodies in their knees. If these pieces consist of just cartilage, they cannot be seen on X-ray.

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Also purchase yasmin 3.03 mg overnight delivery, at the interface there are positive and negative charges separated from one another order yasmin 3.03 mg on line, known as the electrical double layer, which creates an equivalent capacitor at the interface. Thus, the interface can be analogous to a resistor in parallel with a capacitor. Impedance spectroscopy uses alternating current tech- niques to determine the resistive and capacitive nature of the interface. From these experimentally derived R and C values one can determine how difficult or easy it is to transport charge across the interface and also to determine the nature of the electrical double layer. Additional informa- tion can be obtained about the growth and structure of the oxide layer as well. One of the results of these types of experiments is the determination of the polarization resistance. This is a term that describes the ease of ion transport across the interface. Higher polarization resistance implies lower corrosion rates. When this technique was used to assess the polarization resistance of Ti-6Al-4V in Ringer’s solution, Ringer’s with serum, and Ringer’s at pH 1. It was found that the polarization resistance of this alloy decreased with the addition of bovine serum and with a decrease in pH, implying that the corrosion rate increased. This underscores the importance of using appropriate electrolyte fluid when conducting any corrosion testing D. Scanning Electrochemical Microscopy This is a relatively new technique that can be used to analyze and image the local microscopic heterogeneous corrosion behavior of metal–solution interfaces. Scanning electrochemical microscopy uses a solid microelectrode probe to investigate the release of ions from a metal surface on the microscopic scale. It has the ability to obtain images of the corrosion reactions at a metallic surface under a wide variety of conditions. These include assessment of the ease and distribution of oxidation and reduction processes on metal surfaces. While this technique is relatively new to orthopedic biomaterials analysis, it may have significant application to the study of electrochemical processes at implant surfaces. Surface Analytical Techniques These techniques are used to evaluate the surface of metal alloys after they have been exposed to body simulating environments. Surface sensitive techniques include x-ray photoelectron spec- 72 Hallab et al. These techniques are very sensitive and are used to evaluate the outermost surfaces of alloys. These techniques rely on photon–surface interactions and electron–surface interactions to provide chemical information about the oxide layer. They are restricted to the outermost surface because the signal generated comes only from the outer 5 nm or so of the surface. One limitation to many of these techniques involves the use of instruments that require very high vacuums and may alter or affect the nature of the surface. CORROSION-RESISTANT ORTHOPEDIC ALLOYS There are three principal metal alloys used in orthopedics and particularly in total joint replace- ment: titanium based alloys, cobalt based alloys, and stainless steel alloys. The elemental compo- sition of these three alloys is shown in Table 2. Alloy-specific differences in strength, ductility, and hardness generally determine which of these three alloys is used for a particular application or implant component. However, it is primarily the high corrosion resistance of all metal alloys that has led to their widespread use as implant materials. Implant alloys were originally developed for maritime and aviation uses where mechanical properties such as corrosion resistance and high strength are paramount. Stainless Steel Alloys The form of stainless steel most commonly used in orthopedic practice is designated 316LV (American Society for Testing and Materials F138, ASTM F138). The designation 316 classifies the material as austenitic, the L denotes the low carbon content, and V the vacuum under which it is formed. The carbon content must be kept at a low level to prevent carbide (chromium–carbon) accumulation at the grain boundaries.

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