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By R. Shawn. Pensacola Christian College.

This type of joint allows only for bending and straightening motions along a single axis order 100mg voveran sr mastercard, and thus hinge joints are functionally classified as uniaxial joints order voveran sr 100 mg overnight delivery. A good example is the elbow joint, with the articulation between the trochlea of the humerus and the trochlear notch of the ulna. Other hinge joints of the body include the knee, ankle, and interphalangeal joints between the phalanx bones of the fingers and toes. Condyloid Joint At a condyloid joint (ellipsoid joint), the shallow depression at the end of one bone articulates with a rounded structure from an adjacent bone or bones (see Figure 9. The knuckle (metacarpophalangeal) joints of the hand between the distal end of a metacarpal bone and the proximal phalanx bone are condyloid joints. Another example is the radiocarpal joint of the wrist, between the shallow depression at the distal end of the radius bone and the rounded scaphoid, lunate, and triquetrum carpal bones. One movement involves the bending and straightening of the fingers or the anterior-posterior movements of the hand. The second movement is a side-to-side movement, which allows you to spread your fingers apart and bring them together, or to move your hand in a medial-going or lateral-going direction. Saddle Joint At a saddle joint, both of the articulating surfaces for the bones have a saddle shape, which is concave in one direction and convex in the other (see Figure 9. The primary example is the first carpometacarpal joint, between the trapezium (a carpal bone) and the first metacarpal bone at the base of the thumb. Thus, the thumb can move within the same plane as the palm of the hand, or it can jut out anteriorly, perpendicular to the palm. This movement of the first carpometacarpal joint is what gives humans their distinctive “opposable” thumbs. Plane Joint At a plane joint (gliding joint), the articulating surfaces of the bones are flat or slightly curved and of approximately the same size, which allows the bones to slide against each other (see Figure 9. However, not all of these movements are available to every plane joint due to limitations placed on it by ligaments or neighboring bones. Thus, depending upon the specific joint of the body, a plane joint may exhibit only a single type of movement or several movements. Plane joints are found between the carpal bones (intercarpal joints) of the wrist or tarsal bones (intertarsal joints) of the foot, between the clavicle and acromion of the scapula (acromioclavicular joint), and between the superior and inferior articular processes of adjacent vertebrae (zygapophysial joints). At these joints, the rounded head of one bone (the ball) fits into the concave articulation (the socket) of the adjacent bone (see Figure 9. At the hip joint, the head of the femur articulates with the acetabulum of the hip bone, and at the shoulder joint, the head of the humerus articulates with the glenoid cavity of the scapula. The femur and the humerus are able to move in both anterior-posterior and medial-lateral directions and they can also rotate around their long axis. The shallow socket formed by the glenoid cavity allows the shoulder joint an extensive range of motion. In contrast, the deep socket of the acetabulum and the strong supporting ligaments of the hip joint serve to constrain movements of the femur, reflecting the need for stability and weight-bearing ability at the hip. The different types of synovial joints are the ball-and-socket joint (shoulder joint), hinge joint (knee), pivot joint (atlantoaxial joint, between C1 and C2 vertebrae of the neck), condyloid joint (radiocarpal joint of the wrist), saddle joint (first carpometacarpal joint, between the trapezium carpal bone and the first metacarpal bone, at the base of the thumb), and plane joint (facet joints of vertebral column, between superior and inferior articular processes). This often results in significant joint pain, along with swelling, stiffness, and reduced joint mobility. Arthritis may arise from aging, damage to the articular cartilage, autoimmune diseases, bacterial or viral infections, or unknown (probably genetic) causes. The most common type of arthritis is osteoarthritis, which is associated with aging and “wear and tear” of the articular cartilage (Figure 9. Risk factors that may lead to osteoarthritis later in life include injury to a joint; jobs that involve physical labor; sports with running, twisting, or throwing actions; and being overweight. These factors put stress on the articular cartilage that covers the surfaces of bones at synovial joints, causing the cartilage to gradually become thinner. The joint responds by increasing production of the lubricating synovial fluid, but this can lead to swelling of the joint cavity, causing pain and joint stiffness as the articular capsule is stretched. The bone tissue underlying the damaged articular cartilage also responds by thickening, producing irregularities and causing the articulating surface of the bone to become rough or bumpy. In its early stages, symptoms of osteoarthritis may be reduced by mild activity that “warms up” the joint, but the symptoms may worsen following exercise. In individuals with more advanced osteoarthritis, the affected joints can become more painful and therefore are difficult to use effectively, resulting in increased immobility. Treatments may include lifestyle changes, such as weight loss and low-impact exercise, and over-the-counter or prescription medications that help to alleviate the pain and inflammation.

Humoral immunity through immunoglobulin M protects mice from an experimental actinomycetoma infection by Nocardia brasiliensis discount 100 mg voveran sr mastercard. Cytokine gene activation and modified responsive- ness to interleukin-2 in the blood of tuberculosis patients 100mg voveran sr with amex. Phagocytosis of Mycobacterium tuberculosis is mediated by human monocyte complement receptors and complement component C3. Macrophage phagocytosis of virulent but not attenuated strains of Mycobacterium tuberculosis is mediated by mannose receptors in addition to comple- ment receptors. Phosphate is essential for stimulation of V gamma 9V delta 2 T lymphocytes by mycobacterial low molecular weight ligand. Type 2 Cytokine gene activation and its relationship to extent of disease in patients with tuberculosis. Comparison of intranasal and transcutaneous immunization for induction of protective immunity against Chlamydia muridarum respi- ratory tract infection. The ability of heat-killed Myco- bacterium vaccae to stimulate a cytotoxic T-cell response to an unrelated protein is as- sociated with a 65 kilodalton heat-shock protein. Effect of pre-immunization by killed Mycobacterium bovis and vaccae on immunoglobulin E response in ovalbumin- sensitized newborn mice. Arrest of mycobacterial phagosome maturation is caused by a block in vesicle fusion between stages controlled by rab5 and rab7. Inhibition of an established allergic response to ovalbumin in Balb/c mice by killed Mycobacterium vaccae. Mucosal mast cells are functionally active during spontaneous expulsion of intestinal nematode infections in rat. Selective receptor blockade during phagocytosis does not alter the survival and growth of Mycobacterium tuberculosis in human macrophages. Suppression of airway eosinophilia by killed Mycobacterium vaccae-induced allergen-specific regulatory T-cells. Long-term protective and antigen-specific effect of heat-killed Mycobacterium vaccae in a murine model of allergic pulmonary in- flammation. Differential regulation of lipopolysacharide- induced interleukin 1 and tumor necrosis factor synthesis; effect of endogenous and ex- ogenous glucocorticoids and the role of the pituitary-adrenal axis. With the advent of effective antibiotic therapy in the ’50s, the prevalence of the disease, and research on it, declined pre- cipitously. Hippocrates thought it was inherited, while Aristotle and Galen believed it was contagious (Smith 2003). As the disease was more common in particular families and racial or ethnic groups, a heritable component to susceptibility was a plausible assumption, but one that has defied solid experimental proof, perhaps due to the difficulty in eliminating the confounding biases of environment and exposure. While there are several recent reviews of the subject (Bellamy 2005, Bellamy 2006, Fernando 2006, Hill 2006, Ottenhoff 2005, Remus 2003), it is hard to come to definitive conclusions on most of the genes, because the accumulated literature is often contradictory. This has led to the recent publication of meta-analyses attempting to examine the body of published work on particular genes to determine whether a convincing consensus emerges (Kettaneh 2006, Lewis 2005, Li 2006). In addition, it will review studies performed prior to the molecular era to illustrate the history of the field, which may help to clarify why finding genetic determinants has been elusive. The basic epidemiological designs employed in studies of genetic association, in approximate decreasing order of confidence that the results obtained are free of the complicating influences of environment and exposure are: • twin studies comparing disease concordance in monozygotic vs. While this tour is not exhaustive, it attempts to critically present most of the relevant published work. Stocks and Karn (Stocks 1928) devised a correlation coefficient based on sibling disease concurrence expected by chance. Although the attempt was interesting in its design, it could not assure comparability of environment and exposure, as a tuberculous relative could have had a con- founding effect, either as a source of exposure or as a marker for lower socioeco- nomic status. To address the obvious criticism that the spouses could have been exposed in childhood from the affected relative, Puffer stated that two thirds had no known household contact, although the contact may have been forgotten or missed. Overall, due to the near impossibility of controlling for household exposure, the family studies failed to convincingly demonstrate a genetic predisposition. Monozygotic twins are genetically identical, while dizygotic twins are only as genetically similar as other siblings. The concordance in monozygotic twins can also serve as a measure of penetrance − the proportion of gene carriers who express the trait (Cantor 1992).

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This stimulation causes the distal motor neuron to secrete a neurotransmitter (the neurotransmitter is acetylcholine in skeletal muscle) purchase voveran sr 100mg with mastercard. The thin filament will eventually pull the Z line toward the ends of the Chapter 6 - 6 myosin (Z lines move toward each other) causing muscle contraction purchase voveran sr 100 mg without prescription. Astrocytes - most numerous, star shaped bodies, that play a major role in the transfer of materials to and from circulation (so-called blood brain barrier). Dendrites - highly branched, short cell processes which conduct action potentials toward the cell body, (they contain Nissl bodies). Axon - one long cell process which conducts action potentials away from the cell body (they do not contain Nissl bodies). Nerve Impulse - depends on polarization and depolarization of the neuronal membrane (as seen in muscle contraction). Membrane Potentials - are indicated by the difference between the amount of ion concentration outside the plasma membrane. Polarization - potassium (K ) ions are highly concentrated inside cell, and + sodium (Na ) ions are highly concentrated outside cell. Refractory Period - when a nerve receives a second stimulus at such a close internal that no response will occur. The nerve must have sufficient time to recover from the initial stimulus before receiving an additional one. All or none response - If a stimulus is strong enough to initiate an action potential the impulse will travel along a neuron until its transmission is complete. Cervical Enlargement (C4 - T1) - nerves arising from this region are associated with the upper extremities. Lumbar Enlargement (T9 - L1) - nerves arising from this region are associated with the lower extremities. Cauda Equina - after the terminal portion of the spinal cord; composed of the roots of the spinal nerves below the 1st lumbar nerve. Dura mater (tough mother) - a tough outer layer which is fused with the periosteum of the cranial bones and vertebrae; ends at S2. Epidural space - between skull or vertebra and the dura mater; contains a protective padding of adipose tissue. Reflex arc - a neural pathway between the point of stimulation (receptor), to the brain or spinal cord, and to the responding organ (effector). Receptor - receives the stimulation; the beginning of the dendrite of the sensory neuron (see "Receptors" on page ). Each spinal nerve is attached to the spinal cord by two roots: a dorsal or posterior root and a ventral or anterior root. There are 31 pairs of spinal nerves and they are named and numbered according to the region and level of the spinal cord from which they arise: a. A spinal nerve splits right after it is formed into a dorsal ramus (goes to the posterior part of the body) and a ventral ramus (goes to the anterior part of the body) a. The plexus will yield nerves which represent their composition (or most of it) to the front and the side of the body. It is a grouping of anterior rami, and this group forms plexuses; and these plexuses yield more nerves. Cervical plexus - (C1 - C4) - muscles and skin, of posterior scalp; its major branch is the phrenic nerve (C3-C5) to the diaphragm. Brachial plexus - (C5 - T1) - neck and shoulder muscles and upper extremities; major branches are the axillary, musculocutaneous, medial, ulnar, and radial nerves. Lumbar plexus - (L1 - L4) - motor and sensory to the lower abdominal wall, external genitalia, and lower extremity; major branches are the femoral and saphenous nerves. Sacral plexus - (L4 - S3) - muscles and skin of buttocks, perineum and lower extremity; major branches are the sciatic, tibial and fibular (common peroneal) nerves. Cavities in the central nervous system - (known as the ventricular system of the brain and central canal of the spinal cord). Cerebral aqueduct (Aqueduct of Sylvius) - communicating passage way between the 3rd and 4th ventricle. Foramen of Magendie (Median Aperture) - communicating passage between the 4th ventricle and the subarachnoid space of the brain and spinal cord. Each ventricle (cavity) of the brain contains a capillary complex known as a choroid plexus, which produces C.

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The indications for surgery are specific and are as follows:  Doubtful diagnosis requiring excision of the focus or curettage of the lesion voveran sr 100 mg overnight delivery. In case of an osseous lesion voveran sr 100 mg low cost, all sequestra, granulation tissue and caseous material should be removed till new bleeding bone is encountered, so that the antibiotics may reach the site of lesion better. Avoid dead spaces to prevent hematoma formation and close the wound primarily with or without suction. Tuberculosis can involve any bone or joint of the body but in children it has a special predilection for the hip and knee joints commonly, and for ankle and elbow joints rarely. Long bones are rarely involved but the short long bone involvement is somewhat common. Referral Criteria No need to refer anywhere since the patient is already in a tertiary care hospital. Who does What Doctor – Diagnosis, chemo therapy advice and surgery Nurse – General care like nutrition advise, care of the wounds. Introduction: India is classified as a country with a high burden and the least prospects of a favourable time trend of the disease. The average prevalence of all forms of tuberculosis in India is estimated to be 5 per thousand. Neurological complications and progressive deformity are the dreaded complications of tuberculosis of spine. It is imperative to diagonose this condition early and initiate early medical treatment while recognising and treating patients requiring surgical interventions for optimal outcomes. Osteoarticular tuberculosis is always secondary, so primary infection should be treated effectively for sufficient time. Once diagnosed, close follow up, regular anti tubercular treatment and aggressive surgical approach may prevent dreaded complications V. Any back pain not responding to conservative treatment for more than 6 weeks and/or accompanied by constitutional symptoms should be investigated further Neurologic abnormalities occur in 50% of cases and can include paraplegia, paresis, impaired sensation, nerve root pain. The following are radiographic changes characteristic of spinal tuberculosis o Paradiscal involvement with decreased disc space o Increased anterior wedging o Collapse of vertebral body 13 o Enlarged psoas shadow with or without calcification o Fusiform paravertebral shadows suggest abscess formation. Goals of management in active tuberculosis Eradication/ Control of Disease Decompression of spinal cord Prevention of progressive deformity and later neurological complications Early mobilization of the patient. In Patient In patients without deficit,chemotherapy alone is sufficient if the risk of progressive deformity is not there. A close watch on development of neurological symptoms is to be kept and at signs of deterioration, the patient may be referred. In Patient Tuberculosis spine with no neurological deficit Chemotherapy alone is sufficient if there is no risk of progressive deformity Efforts should be made to identify patients who are at risk of developing kyphosis in active disease. Growing children with dorsal and dorsolumbar caries with more than 3 body involvement or in which there is destruction more than 1. Indications of surgery Failure to respond to conservative treatment Deformity/risk of progresion Recurrence of the disease 15 Doubtful diagonosis Tuberculosis spine with neurological deficit Middle path regime In patients with mild deficit trial of chemotherapy can be done, however a close observation is must Indications for surgery for management of tuberculosis with deficit Severe neurologic symptoms Progressive neurologic symptoms Unsuccessful nonoperative treatment Instability with spinal deformity, Spinal tumour syndrome. By providing structural support and by its osteogenic potential, the graft may prevent progression of kyphosis. Anterior grafting procedure should be accompanied by instrumentation either anterior or posterior. Out Patient Regular follow up of operated patients as well as patients on conservative treatment. At each follow-up detailed neurological examination should be performed and serial x rays should be taken and deformity progression should be noted. Doctor Clinical diagnoses Investigations Clinical decision making Surgical procedure Maintenance of record and follow up b. Indications and Timing of surgery There is a definite role of conservative management in neck pain and radiculopathy with minor sensory symptoms. Patients with very mild and subtle signs of myelopathy can be managed conservatively but close observation and regular follow up is must. Once moderate signs and symptoms of myelopathy develop patients are less likely to improve on their own and surgical intervention is required. Manipulation and traction are not recommended in myelopathy because of potential risk of aggravating neurological deficit Indications for surgery in degenerative disease of cervical spine – Cervical spondylotic myelopathy – Radiculopathy with a significant motor deficit – Radicular pain not responding to conservative treatment – Intractable Neck pain due to pseudarthrosis Choice of Surgical approach The decision of which surgical approach is to be used should be based on: 1.

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