Condet

Linda Watkins MBChB MRCOG

• Consultant Obstetrician, Liverpool Woman? Hospital,
• Liverpool

Spinal interneurons containing enkephalin times referred to as hyperpathia (subtly different synapse with the terminals of pain fibers and inhibit the release of the presumptive transmitter cardiovascular question from nclex purchase 30mg procardia fast delivery, from hyperalgesia) cardiovascular bypass generic 30 mg procardia otc. As a result heart disease kawasaki generic 30 mg procardia free shipping, the receptor neuron in the dorsal horn receives less excitatory (pain) impulses and transmits fewer pain impulses to the brain coronary heart 59 buy discount procardia 30 mg on line. Morphine binds to unoccupied en- excessive reaction to all stimuli, even those (such kephalin receptors, mimicking the pain-suppressing effects of the endogenous opiate enkeph- as light touch) that normally do not evoke pain, a symptom termed allodynia. These features are ically to opiate receptors, were identified (see Hughes et al for a exemplified by causalgia, a special type of burning pain that results summary of these substances). These endogenous, morphine-like from interruption of a peripheral nerve (see page 121). They are found in greatsensation (see also Table 9-1) est concentration in relation to opiate receptors in the midbrain. At the level of the spinal cord, exclusively enkephalin receptors are Dysesthesia: Any abnormal sensation described as unpleasant by found. A theoretical construct of the roles of enkephalin (and subthe patient stance P) at the point of entry of pain fibers into the spinal cord is Hyperalgesia: Exaggerated pain response from a normally illustrated in. A subgroup of dorsal horn interneurons also painful stimulus; usually includes aspects of summation with contains enkephalin; they are in contact with spinothalamic tract repeated stimulus of constant intensity and aftersensation neurons. Hyperpathia: Abnormally painful and exaggerated reaction to a Thus it would appear that the central effects of a painful conpainful stimulus; related to hyperalgesia dition are determined by many ascending and descending systems Hyperesthesia (hypesthesia): Exaggerated perception of touch utilizing a variety of transmitters. A deficiency in a particular restimulus gion would explain persistent or excessive pain. Some aspects of Allodynia: Abnormal perception of pain from a normally opiate addiction and also the discomfort that follows withdrawal nonpainful mechanical or thermal stimulus; usually has of the drug might conceivably be accounted for in this way. Indeed, elements of delay in perception and of aftersensation it is known that some of these peptides not only relieve pain but Hypoalgesia (hypalgesia): Decreased sensitivity and raised suppress withdrawal symptoms. A descending norepinephrine-containing pathway, as menParesthesia: Mainly spontaneous abnormal sensation that is not tioned, has been traced from the dorsolateral pons to the spinal unpleasant; usually described as "pins and needles" cord, and its activation blocks spinal nociceptive neurons. The rosCausalgia: Buring pain in the distribution of one or more troventral medulla contains a large number of serotonergic neurons. Skin pain is of two types: a pricking pain, evoked immediately on penetration of the skin by a needle point, and a stinging or burning pain, which follows in a second or two. Compression of nerve by the application of a tourniquet to a limb abolishes pricking pain before burning pain. Like the sensation of a limb "falling asleep," this is not due to ischemia as commonly thought. The first (fast) pain is thought to be transmitted by the larger (A-) fibers and the second (slow) pain, which is somewhat more diffuse and longer-lasting, by the thinner, unmyelinated C fibers. Deep pain from visceral and skeletomuscular structures is basically aching in quality; if intense, it may be sharp and penetrating (knife-like). Occasionally there is a burning type of pain, as in the "heartburn" of esophageal irritation and rarely in angina pectoris. It is diffuse and poorly localized, and the margins of the painful zone are not well delineated, presumably because of the relative paucity of nerve endings in viscera. First, there is tenderness at remote superficial sites ("referred hyperaglesia") and, second, an enhanced pain sensitivity in the same and in neaerby organs ("visceral hyperalgesia"). The concept of visceral hyperalgesia has received considerable attention in a number of pain syndromes in reference to the transition from acute to chronic pain, particularly in headache. It has been speculated that the central mechanism of these syndromes involves glutamate. Referred Pain the localization of deep pain of visceral origin raises a number of problems. Deep pain has indefinite boundaries and its location is distant from the visceral structure involved. It tends to be referred not to the skin overlying the viscera of origin but to other areas of skin innervated by the same spinal segment (or segments). This pain, projected to some fixed site at a distance from the source, is called referred pain. This ostensible explanation for the site of referrral is that small-caliber pain afferents from deep structures project to a wide range of lamina V neurons in the dorsal horn, as do cutaneous afferents. The convergence of deep and cutaneous afferents on the same dorsal horn cells, coupled with the fact that cutaneous afferents are far more numerous than visceral afferents and have direct connections with the thalamus, is probably responsible for the phenomenon. Since the nociceptive receptors and nerves of any given visceral or skeletal structure may project upon the dorsal horns of several adjacent spinal or brainstem segments, the pain from these structures may be fairly widely distributed.

However cardiovascular journal of africa impact factor generic procardia 30mg free shipping, authorities in the field cardiovascular 77068 trusted procardia 30mg, such as Wiles capillaries in your eyes buy 30 mg procardia with amex, whose reviews are recommended (see also Hughes and Wiles) cardiovascular disease risks procardia 30 mg free shipping, warn that unqualified dependence on videofluoroscopy is unwise. They remark that observation of the patient swallowing water and repeated observation of the patient while eating can be equally informative. Having the patient swallow water is a particularly effective test of laryngeal closure; the presence of coughing, wet hoarseness or breathlessness, and/or the need to swallow small volumes slowly are indicative of a high risk of aspiration. Based on bedside observations and on videofluoroscopy studies, an experienced therapist can make recommendations regarding the safety of oral feeding, changes in the consistency and texture of the diet, postural adjustments, and the need to insert a tracheostomy or feeding tube. The first, as the "head ganglion" of the autonomic nervous system, was described in the preceding chapter; the second, as the circadian and seasonal clock for behavioral and sleep-wake functions, was considered in Chap. In the hypothalamus, these systems are integrated with one another as well as with neocortical, limbic, and spinal influences. Together, they maintain homeostasis and participate in the substructure of emotion and affective behavior. The expansion of knowledge of neuroendocrinology during the past few decades stands as one of the significant achievements in neurobiology. It has been learned that neurons, in addition to transmitting electrical impulses, can synthesize and discharge complex molecules locally and into the systemic circulation, and that these molecules are capable of activating or inhibiting endocrine, renal, and vascular cells at distant sites. The concept of neurosecretion probably had its origins in the observations of Speidel, in 1919 (and later those of the Scharrers in 1929), who noted that some of the hypothalamic neurons had the morphologic characteristics of glandular cells. Their suggestion that such cells might secrete hormones into the bloodstream was so novel, however, that it was rejected by most biologists at the time. This seems surprising now that neurosecretion is viewed as a fundamental part of the science of endocrinology. Following these early observations, it was found that certain peptides secreted by neurons in the central and peripheral nervous systems were also contained in glandular cells of the pancreas, intestines, and heart. This seminal observation was made in 1931 by Euler and Gaddum, who isolated a substance from the intestines that was capable of acting on smooth muscle. But it was not until some 35 years later that Leeman and her associates purified the substance and identified it as substance P (see Aronin et al). Then followed the discovery of somatostatin by Brazeau and colleagues in 1973 and the endogenous opioids (enkephalin) by Hughes and coworkers in 1975; since then a series of hypothalamic releasing factors that act on the pituitary gland have been isolated. It is bounded posteriorly by the mammillary bodies, anteriorly by the optic chiasm and lamina terminalis, superiorly by the hypothalamic sulci, laterally by the optic tracts, and inferiorly by the hypophysis. It comprises three main nuclear groups, the standard nomenclature for which was proposed in 1939 by Rioch and colleagues: (1) the anterior group, which includes the preoptic, supraoptic, and paraventricular nuclei; (2) the middle group, which includes the tuberal, arcuate, ventromedial, and dorsomedial nuclei; and (3) the posterior group, comprising the mammillary and posterior hypothalamic nuclei. The lateral part lies lateral to the fornix; it is sparsely cellular and its cell groups are traversed by the medial forebrain bundle- which carries finely myelinated and unmyelinated ascending and descending fibers to and from the rostrally placed septal nuclei, substantia innominata, nucleus accumbens, amygdala, and piriform cortex- and the caudally placed tegmental reticular formation. The medial hypothalamus is rich in cells, some of which are the neurosecretory cells for pituitary regulation and visceral control. Additional structures of importance are the stria terminalis, which runs from the amygdala to the ventromedial hypothalamic nucleus, and the fornix, which connects the hippocampus to the mammillary body, septal nuclei, and periventricular parts of the hypothalamus. The lateral and medial parts of the hypothalamus are interconnected and their functions are integrated. The inferior surface of the hypothalamus, just posterior to the pituitary stalk, bulges downward slightly; this region is known as the tuber cinerium. From the center of the tuber arises the median eminence or infundibulum; the latter stands out because of its vascularity (the hypophysial-portal system of veins courses over the surface). The infundibulum extends into the pituitary stalk, which, in turn, enters the pars nervosa of the hypophysis. The median eminence assumes special importance because of the intimate relation of its cell groups to the anterior lobe of the pituitary gland. It represents the interface between converging pathways from the brain and the master gland of the endocrine system. The supraopticohypophysial fibers terminate on capillaries of the outer zone of the median eminence (Martin and Reichlin). The tuberoinfundibular neurons of the arcuate nucleus and anterior periventricular nuclei synthesize most of the releasing factors described below. The abundant blood supply of the hypothalamus (from several feeding arteries) is of importance to neurosurgeons who attempt to obliterate aneurysms that derive from adjacent vessels. Many small radicles, arising from the posterior and anterior communicating arteries as well as from the most proximal portions of the anterior and posterior cerebral arteries, form a network of such redundancy that infarction of the hypothalamus is infrequent. Readers requiring a more extensive source of information on anatomic and other aspects of the hypothalamus are directed to the comprehensive material by Swaab in the two-volume Handbook of Clinical Neurology and to the monograph by Martin and Reichlin.

Members of both groups of these so-called mildly retarded individuals exhibit a number of noteworthy features that have medical and social implications arteries 2013 proven 30mg procardia. Although not overtly dysmorphic and having a normal or low-normal head circumference cardiovascular system job generic procardia 30 mg on line, they have a high incidence of minor congenital anomalies of the eyes burning blood vessels your nose cheap 30 mg procardia with visa, face arteries resistance vessels generic 30 mg procardia free shipping, mouth, ears, and hands; they tend to be sickly, and the more severely retarded among them have poor physiques and are often undersized. Deviant behavior occurs frequently (in 7 percent of nonretarded children, in 29 percent of the retarded, and in 58 percent of the epileptic retarded, according to Rutter and Martin). Most often, this behavior takes the form of poor self-control and aggressiveness, especially pronounced in children with temporal lobe epilepsy. Other behavioral disturbances are restlessness, repetitive activity, explosive rage reactions and tantrums, stereotyped play, and the seeking of sensory experiences in unusual ways (Chess and Hassibi). Pica (the compulsive ingestion of nonnutritive substances) is a problem between ages 2 and 4 years of age but is also seen in normal neglected children. The parents of a large proportion of children with all of these abnormal behaviors fall into the lowest segment of the population socially and economically; in other words, the parents may lack the competence to maintain stable homes and to find work, for which reason abandonment, neglect, and child abuse are frequent in this group. The majority of children with deviant behavior need to be placed in special classes or schools, and special measures must be taken to reduce the tendency to truancy, sociopathy, and criminality. An endless debate is centered on matters of causation- whether these categories of mild retardation are products of a faulty genetic influence, which prevents successful competition and adaptation, or of societal discrimination and lack of training and education coupled with the effects of malnutrition, infections, or other exogenous factors. Surely both environmental and genetic factors are at work, although the relative importance of each has proved difficult to measure (Moser et al). As mentioned earlier, a pathologic basis for most cases of mild mental retardation has not been established. No visible lesions have been discerned in the brains of this group, unlike those of the severely retarded (pathologic) group, in which malformations and a variety of destructive lesions are obvious in all but 5 to 10 percent of cases. Admittedly, the brains of some of these individuals are about 10 percent underweight, but one cannot at present interpret what this means. It is certain that new methodologies, perhaps relating to neuronal connectivity, will be needed if the cerebra of the subnormal extreme of the general population are to be differentiated from normals. Differences might be expected in terms of the number of neurons in thalamic nuclei and cortex, in dendriticaxonal connectivity, or in synaptic surfaces, elements that are not being assayed by the conventional techniques of tissue neuropathology. The observations of Huttenlocher, who found a marked sparsity of dendritic arborization in Golgi-Cox preparations, and of Purpura, who found an absence of short, thick spines on dendrites of cortical neurons and other abnormalities of dendritic spines, are the first steps in this direction. Renpenning and colleagues reported a series of 21 mentally retarded males in three generations of a Canadian family, all free of any congenital malformations and with normal head size, and Turner and coworkers have described a similar Australian series (page 888). The fragile-X syndrome (page 889) is another in this group, predominating in males and accounting for about 10 percent of all male retardates. Other X-linked forms of mental retardation that have few or no dysmorphic features besides Renpenning and fragile-X syndromes include the Partington, Lowe, Lesch-Nyhan, and Menkes syndromes and adrenoleukodystrophy, each with special characteristics in addition to mental retardation, as discussed in Chaps. Numerous other X-linked retardation syndromes with accompanying neurologic anomalies have been delineated; for example, the one due to a mutation in the oligophrenin gene, in which there is epilepsy, and another involving cerebellar hypoplasia. Diagnosis Infants should be considered at risk for mental subnormality when there is a family history of mental deficiency, low birth weight in relation to the length of gestation (small-for-date babies), marked prematurity, maternal infection early in pregnancy (especially rubella), and toxemia of pregnancy. In the first few months of life, certain of the behavioral characteristics described above are of value in predicting mental retardation. Prechtl and associates have found that a low Apgar score (especially at 5 min after delivery, Table 28-3), flaccidity, underactivity, and asymmetrical neurologic signs are the earliest indices of subnormality in the infant. Slow habituation of orienting reactions to novel auditory and visual stimuli and the presence of "fine motor deficits" (as previously discussed under "Delays in Motor Development") are other early warnings of mental retardation. In the first year or two of life, suspicion of mental retardation is based largely on clinical impression, but it should always be validated by psychometric procedures. For testing of preschool children, the Wechsler Preschool and Primary Scale of Intelligence is used, and for school-age children, the Wechsler Intelligence Scale for Children is preferred. In general, however, normal scores for age on any of these tests essentially eliminate mental retardation as a cause of poor school achievement and learning disabilities; special cognitive defects may, however, be revealed by low scores on particular subtests. Retarded children not only have low scores but exhibit more scatter of subtest scores. Also, like demented adults, they generally achieve greater success with performance than with verbal items. It is essential that the physician know the conditions of testing, for poor scores may be due to fright, inadequate motivation, lapses in attention, dyslexia, or a subtle auditory or visual defect rather than a developmental lag. Is there one domain of faulty psychologic function- such as failure of learning, inattentiveness, or faulty perception- that underlies all forms of mental retardation? Or are there several domains, differing from one case to another or one disease to another?

If the nerve is injured proximal to the origin of the branches to the iliacus and psoas muscles capillaries blood vessels buy generic procardia 30 mg online, there is weakness of hip flexion ryerson arteries 2013 procardia 30mg with amex. The adductor of the thigh (innervated by the obturator nerve) is spared cardiovascular disease treatment purchase 30 mg procardia overnight delivery, distinguishing femoral neuropathy from an L3 radiculopathy cardiovascular workout routines order 30 mg procardia with mastercard. Usually this is the result of improper placement of retractors, which may compress the nerve directly or indirectly by undue pressure on the psoas muscle. Bleeding into the iliacus muscle or the retroperitoneum, observed in patients receiving anticoagulants and in hemophilia patients, is a relatively common cause of isolated femoral neuropathy (Goodfellow et al). The presenting symptom of iliacus hematoma is pain in the groin spreading to the lumbar region or thigh, in response to which the patient assumes a characteristic posture of flexion and lateral rotation of the hip. A palpable mass in the iliac fossa and the signs of femoral nerve compression (quadriceps weakness and loss of knee jerk) follow in a day or two. Sciatic Nerve this nerve is derived from the fourth and fifth lumbar and first and second sacral roots, for which reason a ruptured disc at any of these levels may simulate sciatic neuropathy (sciatica). The sciatic nerve supplies motor innervation to the hamstring muscles and all the muscles below the knee through its two divisions, the tibial and peroneal nerves (see later); the sciatic nerve conveys sensory impulses from the posterior aspect of the thigh, the posterior and lateral aspects of the leg, and the entire sole. In complete sciatic paralysis, the knee cannot be flexed and all muscles below the knee are paralyzed. Weakness of gluteal muscles and pain in the buttock and posterior thigh point to nerve involvement in the pelvis. Lesions beyond the sciatic notch spare the gluteal muscles but not the hamstrings. Partial compressive lesions are more common and tend to involve peroneal-innervated muscles more than tibial ones, giving the impression of a peroneal palsy. As mentioned, rupture of one of the lower lumbar intervertebral discs is perhaps the most common cause of sciatica, although it does not directly involve the sciatic nerve. The associated motor and sensory findings allow localization of the root compression (L4-5 disc compressing L5 root: pain in posterolateral thigh and leg with numbness over the inner foot and weakness of dorsiflexion of the foot and toes; L5-S1 disc compressing S1 root: pain in posterior thigh and leg, numbness of lateral foot, weakness of foot dorsiflexion and loss of ankle jerk) as discussed in Chap. The sciatic nerve is commonly injured by fractures of the pelvis or femur, fracture/dislocation of the hip, gunshot wounds of the buttock and thigh, and the injection of toxic substances into the lower gluteal region. Tumors of the pelvis (sarcomas, lipomas) or gluteal region may compress the nerve. Sitting for a long period with legs flexed and abducted (lotus position) under the influence of narcotics or barbiturates or lying flat on a hard surface in a sustained stupor may severely injure one or both sciatic nerves or branches thereof. The nerve may be involved by neurofibromas and infections and by ischemic necrosis in diabetes mellitus and polyarteritis nodosa. Cryptogenic forms also occur and are actually more frequent than those of identifiable cause. Partial lesions of the sciatic nerve occasionally result in causalgia (see further on). Also mentioned here is the distressingly painful compression of the plantar branches of the sciatic nerve. Common Peroneal Nerve Just above the popliteal fossa the sciatic nerve divides into the tibial nerve (medial, or internal, popliteal nerve) and the common peroneal nerve (lateral, or external, popliteal nerve). The latter swings around the head of the fibula to the anterior aspect of the leg, giving off the superficial peroneal nerve which provides musculocutaneous branches (to the peroneal muscles) and to the deep peroneal nerve (formerly called anterior tibial nerve). Branches of the latter supply the dorsiflexors of the foot and toes (anterior tibialis, extensor digitorum longus and brevies, and extensor hallicus longus muscles) and carry sensory fibers from the dorsum of the foot and lateral aspect of the lower half of the leg. There was weakness of dorsiflexion of the foot in all of the 116 cases of common peroneal neuropathy reported by Katirji and Wilbourn, and numbness of the dorsum of the foot was present in most cases. Weakness of eversion of the foot is usually demonstrable; inversion, a function of the L-5 root and the tibial nerve, is spared and the ankle jerk is normal, unless affected by another process. Pressure during an operation or sleep or from tight plaster casts, obstetric stirrups, habitual and prolonged crossing of the legs while seated, and tight knee boots are the most frequent causes of injury to the common peroneal nerve. The point of compression of the nerve is where it passes over the head of the fibula.

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References

• Davidson JR: Pharmacotherapy of generalized anxiety disorder, J Clin Psychiatry 62(Suppl 11):46-50, 2001.
• Eloubeidi MA, Tamhane A. EUS-guided FNA of solid pancreatic masses: a learning curve with 300 consecutive procedures. Gastrointest Endosc. 2005;61:700-708.
• Taylor LM, Park TC, Edwards JM, et al: Acute disruption of polytetrafluoroethylene grafts adjacent to axillary anastomoses: a complication of axillofemoral grafting, J Vasc Surg 20:520, 1994.
• Mikuls TR, Kazi S, Cipher D, et al. The association of race and ethnicity with disease expression in male US veterans with rheumatoid arthritis. J Rheumatol 2007;34(7):1480-1484.
• Ozgur Tan M, Karaoglan U, Sen I, et al: The impact of radiological anatomy in clearance of lower calyceal stones after shock wave lithotripsy in paediatric patients, Eur Urol 43:188, 2003.
• Sander JC, Bilgutay AN, Stanasel I, et al: Outcomes of endoscopic incision for the treatment of ureterocele in children at a single institution, J Urol 193(2):662n666, 2015.
• Chua JD, Wilkoff BL, Lee I, et al. Diagnosis and management of infections involving implantable electrophysiologic cardiac devices. Ann Intern Med 2000;133:604-608.