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In some instances best doxazosin 1mg, Depending on the extent of permanent alternative methods of communication cheap 4 mg doxazosin mastercard, damage to the brain generic doxazosin 4mg with visa, individuals may use such as writing or using a picture board 4 mg doxazosin with mastercard, assistive devices to perform a variety of may be used generic 1mg doxazosin free shipping. Braces or splints swallowing capabilities, speech pathologists may be necessary to help them increase may also be involved in helping them functional capacity and become inde- learn how to swallow again. Individuals with paralysis of an instances, speech pathologists may also be arm may be taught to use special tools involved in cognitive remediation. If there is paralysis of and/or family members in order to facili- Conditions Affecting the Brain 49 tate the adjustment process. Neuropsycho- venting individuals from functioning to logists may be involved in neurological their maximal capacity. Some neuropsychologists may Several approaches are utilized for indi- also be involved in cognitive retraining or viduals with brain damage after they are remediation, helping individuals with medically stable, including home-based pro- brain damage learn ways to compensate grams, outpatient rehabilitation programs, for areas of lost cognitive function. These programs offer individuals remediation strategies designed to amelio- therapies designed to improve functioning rate sensory/perceptual, language-related, or to help them develop social skills, or and problem-solving deficits may be a they may provide care and supervision for major focus of the rehabilitation effort. Cognitive strengths and weak- Functional Implications of nesses are identified through observation Brain Damage and neuropsychological assessment. How cognitive abilities and limitations in areas Psychological Issues in Brain Damage such as memory, organizational ability, reasoning, or judgment affect individuals’ The emotional reactions experienced by ability to function in the environment is individuals after brain damage can range evaluated, and cognitive strategies are from depression to mood swings or psycho- devised to help them compensate for their sis (Busch & Alpern, 1998). Individuals are extent of personality change or other psy- then helped to transfer these strategies chological symptoms varies from individ- from the clinical setting to their own envi- ual to individual, it is safe to assume that ronment. In some instances, depending whether damage is mild or severe, some on the individuals’ life circumstances psychological symptoms will be exper- and the extent of the brain damage, long- ienced. Those in the early stages Most individuals who have experienced of recovery may deny the extent of their brain damage should abstain from alcohol limitations. Later they may experience or drugs that have not been medically pre- feelings of frustration because of difficul- scribed. The use of alcohol and other sub- ty with memory or because they are un- stances can increase the potential for able to perform tasks they were once able seizures after brain damage. Later feelings of anger, grief, the combination of alcohol or drugs anxiety, or helplessness may occur, or there when taken with prescribed medications may be feelings of worthlessness or guilt. Furthermore, Because of the damage sustained, some alcohol and other substances may accen- individuals are no longer able to compre- tuate any existing residual from brain hend the world around them or respond damage, increasing the chances of addi- to it in the same way they did before. They tional accident or injury as well as pre- may show loss of emotional control in the 50 CHAPTER 2 CONDITIONS OF THE NERVOUS SYSTEM: PART I form of emotional lability, suddenly and their family and toward helping all switching from laughing to crying or cry- involved adjust and relate to each other ing to laughing when there is no appar- in the context of the changes brought ent cause. If emotional lability exists, jury has occurred, individuals may the family may need support and guid- continue in the same pattern of substance ance in dealing with the individual’s out- abuse behavior they were involved with bursts. Consequently, sub- be diverted if the individual’s attention stance abuse evaluation should be con- can be directed to another activity. Substance abuse may also be a ity with regard to money, sex, drugs, or maladaptive means of coping with the interactions with others. In some in- stress and depression individuals experi- stances there may be outbursts of verbal ence following brain damage. They may lose sen- case, the effects of alcohol or other drugs sitivity to the impact of their behavior on further impair individuals’ functioning others. In instances in which individuals ability and also have the potential to inter- are aware of their behavior, they may act with other medications an individual become self-conscious and anxious, avoid- may be taking. In addition, substance ing contact with others, or they may abuse may precipitate a seizure, which the become overcautious and hypervigilant. Abstinence is, therefore, the best or to brain damage may become exagger- policy for individuals with TBI. Some indi- ated after the damage has occurred, or viduals may believe that substance use has there may be dramatic personality change, been a significant part of their social rela- so that an individual who was quiet and tionships. In these instances, they may passive prior to brain damage may become need to learn other circumstances under boisterous and aggressive after his or her which to engage in social activity and injury. A person who was once self- should be encouraged to participate in directed and took initiative may become social and recreational activities that do apathetic and unable to complete tasks not involve alcohol or other drugs. Role changes as a result of injury im- Counseling and/or psychotherapy is an pact not only the individual but also on important part of total rehabilitation in his or her family. Often because of changes most disabling conditions, and it can be in temperament, behavior, and personal- used to treat depression, reduce denial, ity, there is a disruption in family cohe- increase self-esteem, or help individuals sion and feelings of entrapment by family form realistic goals. Depending on the extent of role may be challenging if the individual has change, individuals may feel diminished lost the capacity for insight or is unable social status, social isolation, and conse- to participate in abstract reasoning. Often the seling may be directed toward providing physical ramifications and residuals of the emotional support for both individuals injury are less troublesome for family and Conditions Affecting the Brain 51 friends than the associated behavioral and In other instances, glad to have the indi- personality changes caused by the brain vidual home again, the family may damage. Family structure may be altered because the individual’s condition may alter the Social Issues in Brain Damage roles and functions of other family mem- bers.

The observed ECGs recorded from the chest leads are each the result of voltage changes at a specified point on the surface of the chest generic doxazosin 1mg otc. Unipolar chest leads are desig- nated V1 to V6 and are placed over the areas of the chest _ + Unipolar chest leads buy doxazosin 2mg online. The three limb leads are combined to give the reference voltage (zero) for the unipolar chest lead (V) order 2mg doxazosin with mastercard. The generation of the QRS com- plex in the chest leads can be explained in a way similar to that for lead I cheap 4mg doxazosin visa. The exploratory electrode for an augmented limb lead is an electrode on a single limb generic 1mg doxazosin free shipping. The reference input is the two other limb electrodes connected together. Lead aVR II gives the potential difference between the right arm (ex- III ploring electrode) and the combination of the left arm and the left leg (reference). Lead aVL gives the potential differ- _ + _ ence between the left arm and the combination of the right + arm and left leg. Lead aVF gives the potential difference be- tween the left leg and the combination of the left arm and right arm. A standard 12-lead ECG, including six limb leads and six + chest leads, is shown in Figure 13. The ECG is calibrated so that two dark horizontal lines (1 cm) represent 1 mV, + and five dark vertical lines represent 1 second. Einthoven codified the analysis of electrical activity of the heart by The ECG Provides Information About Cardiac proposing that certain conventions be followed. The heart is con- Dipoles as Vectors sidered to be at the center of a triangle, each corner of which serves as the location for an electrode for two leads to the ECG Cardiac dipoles are vectors with both magnitude and di- recorder. The net vector produced by all cardiac dipoles at a tion, one electrode causes an upward deflection on the recorder given time can be determined from the ECG. The direction when it is under the influence of a positive dipole relative to the of the vectors can be determined in the frontal and hori- other electrode. The bipolar limb leads (leads I, II, and III) and the aug- ward the positive end of the axis of a lead results in the mented limb leads (aVR, aVL, and aVF) provide informa- recording of an upward deflection. A net cardiac dipole with tion about the electrical activity of the heart as observed in its positive charge directed toward the negative end of the the frontal plane. As we have seen, lead I is the record of axis of a lead results in a downward deflection. It dipole with its positive charge directed at a right angle to the records only the component of the electrical vector that is axis of a lead results in no deflection. Lead I can be symbolized by a horizon- system can be used to predict the influence of a cardiac di- tal line (axis) going through the center of the chest (Fig. Likewise, see, this system is useful in understanding changes in the lead II can be symbolized by a 60 line drawn through the leads of the ECG associated with different diseases. The unipolar chest leads provide information about car- The same type of representation can be done for lead III diac dipoles generated in the horizontal plane (Figure and for the augmented limb leads. Each chest lead can be represented as having an leads are shown by the arrowheads (see Fig. The axis coming from the center of the chest to the site of the diagram that results (see Fig. Superior -90 Posterior -120 -60 -150 -30 ++__ I 0 Right 180180 Left Right V 0 Left 6 +150+150 +30+30 V5 30 +120 +60 +90 V 4 V1 V2 V3 60 75 A Inferior Anterior B FIGURE 13. B, Chest leads are influenced by dipole vectors give information on cardiac dipole vectors in in the horizontal plane. CHAPTER 13 The Electrical Activity of the Heart 231 The Mean QRS Electrical Axis Is Determined Lead I _ +10 + From the Limb Leads RA 0 +5 LA _ _ As explained above, changes in the magnitude and direction of the cardiac dipole will cause changes in a given ECG lead, as predicted by the axial reference system. By examining the -10 limb leads, the observer can determine the mean electrical -5 axis during ventricular depolarization. One approach in- 00 00 Lead II +5 Lead III volves the use of Einthoven’s triangle.

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The iron is granulocytes have been identified based on staining reac- released cheap 2mg doxazosin, reduced intracellularly to the ferrous state doxazosin 1 mg mastercard, and ei- tions of their cytoplasm with polychromatic dyes: neu- ther incorporated into heme or stored as ferritin order doxazosin 4 mg free shipping, a complex trophils order 4mg doxazosin overnight delivery, eosinophils discount doxazosin 1mg line, and basophils. Neutrophils are usually the most prevalent catabolized to hemosiderin, an insoluble compound con- leukocyte in peripheral blood. The accumula- spond instantly to microbial invasion by detecting foreign tion of large amounts of hemosiderin formed during periods proteins or changes in host defense network proteins. Neu- of massive hemolysis can result in damage to vital organs, in- trophils provide an efficient defense against pathogens that cluding the heart, pancreas, and liver. Defects The recycling of iron is quite efficient, but small in neutrophil function quickly lead to massive infection— amounts are continuously lost. The majority of bacteria induce neutrophil chemotaxis—migration to the iron in the diet is derived from heme in meat (“organic site of infection. Chemotaxis is initiated by the release of iron”), but iron can also be provided by the absorption of chemotactic factors from the bacteria or by chemotactic inorganic iron by intestinal epithelial cells. Chemo- iron attached to heme is released and reduced to the fer- tactic factors are generated when bacteria or their products 2 bind to circulating antibodies, by tissue cells when infected rous form (Fe ) by intracellular flavoprotein. The re- duced iron (both released from heme and absorbed as the with bacteria, and by lymphocytes and platelets after inter- inorganic ion) is transported through the cytoplasm action with bacteria. When it is released to After neutrophils migrate to the site of infection, they the plasma, it is oxidized to the ferric state and bound to engulf the invading pathogen by the process of phagocy- transferrin for use in heme synthesis. Phagocytosis is facilitated when the bacteria are coated with the host defense proteins known as opsonins. A burst of metabolic events occurs in the neutrophil af- Platelets Participate in Clotting ter phagocytosis (Fig. In the phagocytic vacuole or phagosome, the bacterium is exposed to enzymes that Platelets are irregularly shaped, disk-like fragments of the were originally positioned on the cell surface. Membrane-bound enzymes, activated when the where they function in hemostasis. Several factors stimu- phagocytic vacuole closes, work in conjunction with en- late megakaryocytes to release platelets, including the hor- zymes secreted from intracellular granules into the phago- mone thrombopoietin, which is generated and released cytic vacuole to destroy the invading pathogen efficiently. They are adenine dinucleotide phosphate (NADPH) oxidase, pro- one fourth to one third the size of erythrocytes. Superoxide is an unstable possess physiologically important proteins, stored in intra- free radical that kills bacteria directly. Superoxide also cellular granules, which are secreted when the platelets are participates in secondary free radical reactions to generate activated during coagulation. The role of platelets in blood other potent antimicrobial agents, such as hydrogen per- clotting is discussed below. Superoxide generation in the phagocytic vacuole proceeds at the expense of reducing agents oxidized in the cytoplasm. The reducing agent, NADPH, is generated Leukocytes Participate in Host Defense from glucose by the activity of the hexose monophos- Each of the three general types of leukocytes—myeloid, phate shunt. Aerobic cells generate reduced nicotinamide lymphoid, and monocytic—follows a separate line of de- adenine dinucleotide (NADH) and ATP when glucose is velopment from primitive cells (see Fig. The hexose monophosphate cells of the myeloid series are termed granulocytes, based shunt operates in neutrophils and other cells when large 198 PART IV BLOOD AND CARDIOVASCULAR PHYSIOLOGY 1. Invagination chemiluminescence) when they oxidize components in the bacterial cell wall. Other bactericidal agents and processes operate in neu- trophils to ensure efficient bacterial killing. Phagocytized bacteria encounter intracellular defensins, cationic proteins that bind to and inhibit the replication of bacteria. De- fensins and other antibacterial agents pour into the phago- cytic vacuole after phagocytosis. Agents stored in neu- trophil granules include lysozyme, a bacteriolytic enzyme, Cell-surface receptors Cell membrane sense invading pathogens surrounds microbes and myeloperoxidase, which reacts with hydrogen perox- ide to generate potent, bacteria-killing oxidants. One of the oxidants generated by the myeloperoxidase reaction is hypochlorous acid (HOCl), the killing agent found in 4. Eosinophils are rare in the circulation but are easily identified on stained blood films. As the name im- plies, the eosinophil takes on a deep eosin color during polychromatic staining; the large, refractile cytoplasmic granules of these cells stain orange-red to bright yellow. Cellular granules release contents into vacuole; membrane Like neutrophils, eosinophils migrate to sites where they NADPH oxidase is activated are needed and exhibit a metabolic burst when activated.

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If present generic 1 mg doxazosin visa, infection of these enzymes contribute to the degradation of the should be suspected buy doxazosin 1mg fast delivery. The neuropathic foot may also be proteoglycan matrix of the collagen and cartilage investigated by a combination of Tc99-MDP and tagged ground substance cheap doxazosin 2 mg visa. Comparison with plain films is useful in tended to protect the joint ultimately leads to its de- nearly all cases doxazosin 1mg sale. The ones of clinical concern are the soft-tissue swelling over the medial side of the forefoot and the dislocation of the second metatarsal-phalangeal joint 1 mg doxazosin visa. Jason Mehrling, Denver, Colorado, USA Osteomyelitis and Septic Arthritis 141 Organisms Related to Septic Arthritis Management Neisseria gonorrhoeae and Staphylococcus aureus are The goal is to prevent joint destruction. With typical clinical signs of infection and easy ac- teria (Pseudomonas aeruginosa and Escherichia coli) are cess to the joint fluid, the radiologist is generally not in- associated with intravenous drug abuse or urinary tract in- volved in the diagnostic workup of the patient with acute fection. Fungal infection occurs in patients with decreased monoarticular arthritis. Haemophilus influen- volving the radiologist are useful in the more difficult zae is seen in children from 6 months to 3 years of age. Computed tomography or fluoroscopy is recom- mended for guidance of needle placement, with injection Clinical Findings of contrast at the end of the procedure to confirm the in- traarticular position of the needle. This is particularly use- The typical patient presents with acute onset of pain, ful in joints such as the hip, sacroiliac joint and shoulder. If the in- If there is a question of monoarticular inflammatory fection is due to hematogenous spread, there may be signs arthritis, MRI may be useful to demonstrate the presence of systemic illness. Establishing the presence of fluid in the proper clinical situation then mandates aspiration using The radiographic changes reflect the underlying pathophys- CT guidance. Hyperemia causes juxtaarticu- Tuberculous Arthritis lar demineralization. Proteolytic enzymes result in uniform destruction of the cartilage with uniform joint-space nar- In the Los Angeles community, as well as the rest of the rowing (Fig. Pannus formation causes marginal ero- world, we are seeing a rise in tuberculosis (TB) in epi- sions. Tuberculous arthritis and tuberculous spondylitis must be considered in musculoskeletal infec- tions. A diagno- sis of TB should be considered in patients who are im- munosuppressed or who are immigrants from third-world countries. In this subset of patients, obtaining mater- ial for culture should include culture for acid-fast bacillus. Tuberculous exudate lacks the high concentration of proteolytic enzymes observed in pyogenic arthritis. Hence, there is often relative preservation of the cartilage associated with juxtaarticular demineralization and mar- ginal erosions. The absence of simultaneous joint- space narrowing, in the presence of destructive marginal erosions, should alert one to the possibility of a non-pyo- genic process. Tuberculous arthritis and tuberculous spondylitis have a tendency to be associated with a cold abscess. The abscess may predominate, giving a mis- leading clinical picture that this is a soft-tissue tumor. MRI may help in differentiating pyogenic and tubercu- lous skeletal infection. This man had lacerations over the knuckles after hitting Coccidioidomycosis is endemic in Mexico and the someone in a bar fight. The radiograph of this closed-fist injury was taken a week after the fight and shows destruction of the third southwestern United States. The fungus is disseminated metacarpal-phalangeal joint due to infection by mouth bacteria in dust that is inhaled. Kilcoyne tion as well as the darker-skinned races are most sus- value of SPET/CT in chronic osteomyelitis. Schweitzer ME, Morrison WB (2003) MR imaging of the di- tis may accompany the respiratory infection.

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