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Normal electron microscope picture of kidney filtering unit “glomerulus” this is a picture of a healthy kidney under an electron microscope. Podocyte and pedicels are foot processes that extend from the filtration membrane. Tissues that line inner space of the capillary lumen are called “endothelial” and the tissues that line outer space of the capillary lumen including podocytes and pedicles are called “epithelial”. Normal immunofluorescence stain of kidney filtering unit “glomerulus” Types of Glomerular Disease 1/2 Proteinuria and blood in urine (hematuria) are the most common manifestations of glomerular diseases. Types of Glomerular Disease 2/2 Glomerular diseases can also be classified by the parts of the kidney effect. However both primary and secondary glomerular diseases share same histological and clinical characteristics. People with Scleroderma and without renal crisis usually have non specific inflammation as opposed to dramatic arterial Changes. Department of Medicine Dermatology/Pharmacogenomics Center for the Study of Itch McDonnell Basic Sciences 770 cristinastrong@wustl. Example: For polydactyly, an extra digit may occur on one or more appendages, and the digit can be full size or just a stub. Nature March 23 2011 Advance issue Copy Number (Structural) Variation Structural variation of the genome kilobase to megabase sized deletions, duplications, insertions, Inversions complex combinations of rearrangements. PathoGenetics 2008 1:4 Genomic rearrangements in the genome are likely to be more common than expected 5% of human genes are found in interspersed duplicated copies Recent examples of large rearrangement polymorphisms in the human genome • Sebat et al. Science 305:525 8 (2004) • A common inversion under selection in Europeans Stefansson et al. Nature Genetics 37, 129 137 (2005) Chromosome 17q21 H1 H2 900kb A common inversion under selection in Europeans Stefansson et al. The mitochondrial genetic bottleneck Mitochondrial genome • Cytoplasmic organelle • Small genome (~16kb) • 1/200,000 size of nuclear genome • Sequenced in 1981 (Anderson et al. This meaning implies that the primary defect is within the muscle, as opposed to the nerves ("neuropathies" or "neurogenic" disorders) or elsewhere. They usually affect muscle without involving the nervous system or any disorder of the neuromuscular junction. Some conditions, such as myositis, can be considered both neuromuscular and musculoskeletal. Abnormalities of muscle cell structure and metabolism lead to various patterns of weakness and dysfunction. In some cases, the pathology extends to involve cardiac muscle fibers, resulting in a hypertrophic or dilated cardiomyopathy. The temporal course, the pattern of muscle weakness, and the absence or presence of a family history of myopathy help distinguish between the two types Acquired Myopathies & Inherited myopathies Acquired myopathies: Inflammatory Myopathy Dermatomyositis and polymyositis 417 Primary polymyositis (idiopathic adult). Congenital myopathies Chronic, slowly progressive Systemic myopathy late onset, acute or sub acute Endocrine myopathies Adult onset, acute or sub acute Inflammatory &toxic Onset in any age, acute or sub acute General signs and symptoms of myopathy include the following: Symmetric proximal muscle weakness is typical. The acuity of symptom onset may aid in the diagnosis, as follows: Weakness progressing over hours: Possible toxic etiology or one of episodic paralyses Weakness developing over days: May be an acute dermatomyositis or Rhabdomyolysis Symptom development over a period of weeks: May be polymyositis, steroid myopathy, or myopathy resulting from endocrine causes. Less common forms of myopathy(muscular dystrophy)in a nutshell Type When it Specific symptoms Other body part involved Starts Weakness of shoulder, face Mental retardation, between and upper arm muscles but cataracts. Dystrophies (or muscular dystrophies) are a subgroup of myopathies characterized by muscle degeneration and regeneration. Onset clinical features Prognosis Childhood Progressive weakness of the girdle Death usually occurs by age 25 onset muscles, bilateral symmetrical, typically from lung disorders. In the ambulatory (3 to 5 yr) phase, pelvic girdle>shoulder girdle Extensor group weaker than flexor group. The non dominant Achilles reflex is usually the last to disappear; this is because the heel cord is the strongest tendon in the body. The specific gravity of this muscle is less than normal because of replacement by adipose and fibrous tissue. But in case of congenital muscular dystrophy, breathlessness is noticed even when the person is still walking. It also causes difficulty in coughing which increases the accumulation of mucus in the lungs. Persons are at risk of aspiration pneumonia due to failure of swallowing muscle function. Heart Complications • Involvement of the heart is very common in muscular dystrophy patients. Myotonic dystrophy type 1 has more than one system affected with prominent heart problems leading to an increased incidence of sudden death. Psychosocial complications: • People with muscular dystrophy may experience psychological & social difficulties due to their limited ability to participate in many activities when their friends are doing well. Obesity: • People with muscular dystrophy often are overweight due to lack of physical activity. Contractures: • Contractures are shortening and tightening of the muscle tissue due to which there is restriction in joint movements. Pressure Sores • Staying for long time in any particular position in muscular dystrophy could result in pressure or bed sore. Food or drink may go down the wrong way (goes to breathing path instead of going to stomach). Complications due to prolonged steroid treatment include: • Cataracts • Cushingoid features(moon face) • Obesity • Short stature • Constipation • Hypertension • Delayed puberty • Behavioral changes (irritability, hyperactivity) • Occasionally slight increase in body hair. May present with pes cavus, unusual hypertrophy (thenar eminence), or patellar subluxation secondary to quadriceps weakness. Autosomal recessive (many sporadic); consanguineous mating increases incidence (for. Popeye arms muscles above elbow are atrophied, those below normal, Strong brachioradialis, but sometimes marked atrophy of biceps. Can be confused with Becker’s Dystrophy,KugelbegWelanderdisease,metabolicmyopathies,congenital myopathies,Polymyositis and acid maltase deficiency Facioscapulohumeral muscular dystrophy (landouzy dejerine disease). But Childhood form is a more malign disease which runs a more rapidly disabling course. Distal leg weakness of tibialis anterior and toe extensors causes foot drop and slapping gait. Occasionally cauda equina syndrome with leg paresthesias secondary to sway back may occur Involvement usually asymmetrical in distribution and degree. The syndrome of Facioscapulohumeral muscle weakness & wasting can be seen in such diverse conditions as myotubular myopathy, central core disease, nemaline myopathy, myasthenia gravis, polymyositis, adult acid maltase deficiency, & spinal muscular dystrophy. Usually autosomal dominant, onset in third to fourth decade, disease is Progressive with frequently asymmetrical distribution; women affected more than men. Morphologically specific myopathies (So called as benign or congenital myopathies) Major structural types—histological diagnosis. Occasionally rapid progression of disease 445 e) Can overlap with some of metabolic myopathies. Congenital dislocation of hip, particularly in central core disease, Responds poorly to closed reduction because of muscle weakness, usually requires operative stabilization ii. Biopsy reveals specific identifying histological abnormalities as seen by light or electron microscopy & in many cases type l fibre predominance. Metabolic myopathies Myopathies of varying degree, secondary to biochemical defects of muscle metabolism. Glycogenosis the seven recognized type muscles disease associated with enzyme deficiency in the carbohydrate metabolism of muscles are outlined in table.
Divalproex sodium Intravenous administration of 500mg can break a migraine Butorphanol (Stadol) this is available in a nasal inhalation formulation; given early may be able to symptoms 5dp5dt fet discount procyclidine 5mg online abort a migraine attack Opioids Morphine sulfate 2 4mg or comparable dose of another parenteral opioid can be useful in breaking a migraine attack treatment 3rd degree heart block order procyclidine overnight. Oxygen Inhalation this treatment can be given in conjunction with other interventions medications voltaren cheap procyclidine 5mg with visa. Prochlorperazine Rectal suppositories 25 mg twice daily may cause sedation Promethazine Rectal suppositories 12 medications not to take during pregnancy order procyclidine master card. Amitriptyline for the treatment of chronic tension type headaches: A randomized clinical trial. Spinal manipulation in the treatment of episodic tension type headache: A randomized controlled trial. Clinical case series: the use of prazosin for combat related recurrent nightmares among operation iraqi freedom combat veterans. Impact of preventive therapy with nadolol and topiramate on the quality of life of migraine patients. Characteristics and Treatment of Headache After Traumatic Brain Injury: A Focused Review. Headache after moderate and severe traumatic brain injury: a longitudinal analysis. Observation and patient interview are key elements to the exam and often guide the clinician in determining the plan of care. Evaluation should include a thorough neurologic examination and the following systems review: vision (acuity, tracking, saccades, nystagmus), auditory (hearing screen, otoscopic exam), sensory (sharp, light touch, proprioception, vibration), motor (power, coordination) and vestibular (dynamic acuity, positional testing). Evaluation of functional activities should include sitting and standing (Romberg with eyes open/closed, single leg stance) balance, transfers (supine sit, sit stand) and gait (walking, tandem walking, turning). The temporal relationship to the onset of dizziness and the initiation/dosing of these medications should be investigated. Initiating vestibular suppressants for dizziness may delay central compensation or promote counterproductive compensation (Hain & Yacovino, 2005; Pyykko I, 1988). Vestibular suppressants might be helpful during the acute period of several vestibular disorders but have not been shown to be effective in chronic dizziness after concussion (Zee, 1985). Medications should only be considered if symptoms are severe enough to significantly limit functional activities. First line medication choice would be meclizine, followed by scopolamine and dimenhydrinate depending upon symptom presentation. Pharmacotherapy with clonazepam, diazepam or lorazepam should be carefully considered due to their sedating and addictive qualities. Non pharmacologic interventions for post traumatic dizziness may be useful as an alternative to pharmacotherapies (de Kruijk et al. Efficacy of vestibular and balance rehabilitation has been found in different populations with vestibular disorders (Herdman et al. Patients with vestibular disorders who received customized programs showed greater improvement than those who received generic exercises (Shepard & Telian, 1995). Studies utilizing vestibular exercises have shown up to 85% success rate in reducing symptoms and improving function in the population with peripheral vestibular disorders (Krebs et al, 2003; Shepard & Telian, 1995). Knowledge of the canalith repositioning procedures (Fife, 2008) for the treatment of benign positional vertigo would be beneficial for primary care physicians. The types of exercise to treat dizziness and disequilibrium are beyond the scope of this guideline. Central and psychological disorders need a coordinated team effort to address the underlying impairments to maximize outcome of vestibular rehabilitation. Mild traumatic brain injury: A neuropsychiatric approach to diagnosis, evaluation, and treatment. Altered balance control following concussion is better detected with an attention test during gait. Persistent post concussive syndrome: the structure of subjective complaints after mild traumatic brain injury. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. Vestibular adaptation exercises and recovery: acute stage after acoustic neuroma resection. Arch Otolaryngol Head Neck Surg 2007;133:170 176 Shumway Cook A: Assessment and management of the patient with traumatic brain injury and rd vestibular dysfunction. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. A detailed history looking at pre/post injury level of physical activity, cognitive function and mental health is important to determine the effects of fatigue in relation to the injury. The ability to maintain a job is often a good measure of the impact of this symptom. Several outcome measures exist for fatigue and many have been studied in other diagnostic populations. Due to the large number of centrally acting medications, a medication review is necessary. Review of illicit drugs, alcohol, tobacco and caffeine/other stimulants should be performed. Modifiable factors should be addressed and typical conservative measures taken prior to initiating pharmacotherapy for fatigue. Several stimulants have had success in other disease states associated with fatigue. Use of neurostimulant medications is contraindicated if there is a history of substance abuse. Educational efforts should be in the areas of factors contributing to fatigue, importance of well balanced meals, promotion of sleep hygiene and regular exercise. Exercise routines should be individualized to maximize benefit and promote proper ratio of activity/rest. Scheduling of exercise may need to be addressed depending upon when the patient is at his or her best. A randomized trial of Modafinil for the treatment of fatigue and excessive daytime sleepiness in individuals with chronic traumatic brain injury. An evaluation of subjective and objective measures of fatigue in patients with brain injury and healthy controls. Fatigue and post concussion syndrome following mild traumatic brain injury: A preliminary report from a New Zealand sample. Mild traumatic brain injury and fatigue: Preliminary findings from a longitudinal prospective study. Impact of additional extracranial injuries on outcome after mild traumatic brain injury. Persistent difficulty falling asleep or staying asleep despite the opportunity (insomnia) is a common symptom of post trauma. Two types of these disorders have been observed: delayed sleep phase syndrome and irregular sleep–wake pattern. Sleep apnea, depression, pain, and other conditions may contribute to the overall poor quality of sleep. Cognitive behavioral sleep interventions have also been shown to be effective in normalizing sleep, these might include sleep restriction, sleep hygiene education, relaxation training and others. The goals of sleep management should be to establish a regular, unbroken, night time sleep pattern and to improve perceptions of the quality of sleep. The aim of sleep management is to establish a regular, normalized sleep wake pattern. Patients should be encouraged to: • Avoid alcohol • Restrict the night time sleep period to about eight hours • Avoid going to bed too early in the evening • Avoid stimulants, caffeinated beverages, power drinks, and nicotine during the evening period • Arise from bed at a regular time in the morning. Provide information • Provide information on good sleep habits about the potential effects of medications, with specific suggestions to improve the caffeine, tobacco, and alcohol on sleep. Pain can be caused by any of a number of co morbid conditions as well as musculoskeletal injuries or secondary damage to soft tissue. Assessing patients for pain and its underlying causes is an essential component of the clinical work up. It is important to attribute symptoms correctly and to identify and treat any comorbid conditions.
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