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In this position, strength and stamina training were improved, together with balance and postural control. Therapist stabilising the left hip laterally from the greater trochanter to facilitate hip abductor, extensor activity. In addition the recruitment of linear extension throughout the lower limb, pelvic girdle and trunk provided a foundation of stability for the upper limb to function. Intensive hand stimulation, palmar posturing and stability improved function in tasks (. Issues of musculoskeletal shortening within the thenar eminence and palmar structures were addressed through the facilitation of length on a more appropriately aligned wrist joint (generally anteriorly subluxed). While promoting this improved postural control of the wrist and hand, the index nger was able to express emerging selective movement for function on the key board 8. Therapist provides initial stability of the second proximal interphalangeal joint for appro priate force and activation of the index nger. The transfer revealed difficulties with musculoskeletal structures (knee pain) as well as strength issues 8. Work is continuing to achieve this goal more independently; however this is lim ited to therapeutic practice within the treatment sessions as continuing this task practice alone at home for this gentleman is not practical. Specic mobilisation and strengthening of his hand, functional task practice and mental imagery formed the basis of a home programme. Effective results included improved lateral rotation at the shoulder, which helped in holding his guitar, together with a greater digitisation and selectivity of the left hand (. Evaluation of outcomes the patient was assessed at the start and end of an 8-week period. The Motor Club Assessment measure is a 30-point test, 10 of which are for the upper limb, and focuses on shoulder, arm and hand activity (Ashburn 1982). Gains include pinch grip, the early pre-shaping of his hand for chord positions on the guitar and improved use of kitchen objects such as using a tin opener. All interactions 202 Exploring Partnerships in the Rehabilitation Setting Table 8. The patient needs to be able to develop and maintain the quality of movement in a range of different environments for tasks to become truly functional and trans ferable to everyday life. Making progressive adaptations to the environment pro vides enriched sources of afferent control whilst varying the challenges of the task for the patient. This involves creating opportunities for practice and includes involving all members of the multidisciplinary team when appropriate. Alternative strategies for stroke care: A pro spective randomised controlled trial. Beyond this the illustrated text will help in reviewing and in the preparation for examinations. For the practising veterinarians, the book-atlas remains a current quick source of reference for anatomical infor mation on the dog at the preclinical, diagnostic, clinical and surgical levels. Therefore, it provides students with an excellent working know ledge and understanding of the anatomy of the dog. Kitts, West Indies Science Illustrator Wolfgang Fricke Renate Richter Co worker Dr Anita Wunsche and Dr Sven Reese Contributions to Clinical and Functional Anatomy by Dr Sven Reese, Dr Klaus Gerlach and Professor Klaus-Dieter Budras Introduction to Radiographic Technique and Ultrasound Diagnosis Professor Cordula Poulsen Nautrup Introduction to Computed Tomography Dr Claudia Noller Co-workers on the Atlas of the Anatomy of the Dog Fourth and Fifth Edition Title Figure: Renate Richter Editor: Prof. Klaus-Dieter Budras, Institut fur Veterinar-Anatomie, Freie Universitat Berlin Contributions: Prof. Hans-Georg Liebich, Institut fur Tieranatomie, Ludwig-Maximilians-Universitat Munchen Dr. Cordula Poulsen Nautrup, Institut fur Tieranatomie, Ludwig-Maximilians-Universitat Munchen Dr. Sven Reese PhD, Institut fur Tieranatomie, Ludwig-Maximilians-Universitat Munchen Dr. Silke Buda, Institut fur Veterinar-Anatomie, Freie Universitat Berlin Index: Thilo Voges, Institut fur Veterinar-Anatomie, Freie Universitat Berlin An index of earlier co-workers and of the sources for illustrations, radiographs, and photographs can be obtained from the previous edition. The contents of this book both photographic and textual, may not be reproduced in any form, by print, photoprint, phototransparency, microfilm, video, video disc, microfiche, or any other means, nor may it be included in any computer retrieval system, without written permission from the publisher. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. Articulations of the vertebral column and of the thorax; atlanto-occipital joint and atlanto-axial joints (A. Medial veins of the thoracic limb; medial shoulder and arm muscles and their nerve supply. Lateral veins of the thoracic limb; lateral shoulder and arm muscles and their nerve supply. Inguinal region, inguinal space (inguinal canal), neuromuscular and vascular lacunae. Blood vessels, nerves, and lymphatic system of the lungs; aortic arch; lymph nodes of the thoracic cavity, thymus. Heart, surface of the heart, heart wall and relationships in the interior of the heart. Peritoneal cavity, lymph nodes of stomach and intestine, cisterna chyli and spleen. Autonomic nervous system, abdominal aorta, caudal vena cava, sublumbar muscles and the lumbar plexus. The medial saphenous vein, obturator nerve, femoral nerve, medial thigh muscles, femoral space (femoral canal). The lateral saphenous vein, common peroneal nerve and tibial nerve; crural (leg) muscles and popliteus muscle. Internal (deep) muscles of mastication, trigeminal nerve (V), mandibular nerve (V3), maxillary nerve (V2). Rhinencephalon, sites of egression of the cranial nerves, arterial supply of the brain. Cerebral veins, sinuses of the dura mater, cerebral ventricles and choroid plexuses. Olfactory and gustatory (chemical) senses; superficial, deep, and visceral sensibility. Osteology: membranous and chondral ossification; growth of bones in length and diameter. Boldface terms of anatom ical structures serve for emphasis and, insofar as they are identified by numbers, they are represented on the neighboring illustration-page where they are identified by the same number. Other abbreviations are explained in the appertaining text, and in the titles and legends for the illustrations. The tendency to shorten the time cedure offers the enormous advantage that comprehensive subjects can be for anatomical education has existed for a longer time, which to a moder imparted with brevity in a natural reality. For the practicing veterinarian ate degree seems to be acceptable and unavoidable for the creation of free the topographical plates are suitable for orientation at surgical operations.

Syndromes

  • Diuretics
  • High-dose radiation brachytherapy lasts about 30 minutes. Your doctor inserts the radioactive material into the prostate. The doctor may use a computerized robot to do this. The radioactive material is removed right away after treatment.
  • Breathing - slow and labored
  • Osteoid osteoma
  • Control bleeding by applying direct pressure to the wound. Raise the injured area. If the bleeding continues, recheck the source of the bleeding and reapply direct pressure, with help from someone who is not tired. If the person has life-threatening bleeding, a tight bandage or tourniquet will be easier to use than direct pressure on the wound. However, using a tight bandage for a long time may do more harm than good.
  • To follow people who have had high cholesterol levels and are being treated
  • Increased risk for infections due to anti-rejection (immunosuppression) medications
  • Reactions to medications

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B, expose the 20ml of saline; no resistance should be found, and the saphenous vein and tributaries (note the medial axis of the long varicosities should be shown to bulge (35-4D). If this is the case, introduce the stripper (one with a E, pass the stripper through the groin downwards. Make sure you have put the stripper inside the saphenous vein and not the femoral! Scrub the groin thoroughly with betadine and make sure Release the haemostat, if applied, and manipulate the the legs are well washed beforehand. Try to get it to mid-calf position; do not try to go as Also find and mark the perforating veins, using the finger far as the ankle where nerves are close to the vein and pressure method described above. You may have to open the vein between Make a 5cm oblique incision 1-2cm below and parallel to ligatures to do this successfully. Deepen the incision, When the stripper has reached its destination, make a 2cm until you reach the superficial fascia. Proceed carefully incision over the olive, dissect out the vein, pass looped using non-toothed dissecting forceps, spreading the fatty ligatures underneath the vein at two sites, tie the lower tissues gently with scissors to expose the saphenous vein ligature tight and divide the vein. Use at least Select prominent remaining varicosities, and by spreading 2 assistants to turn the patient by a log roll and lay him forceps raise a loop of varicose vein by gentle blunt prone with the feet apart, and the knees slightly flexed. Follow it as carefully as you can in each Put pillows under the chest and pelvis, and make sure the direction and when you have exposed as much length of neck is supported, and the abdomen can move freely. There is usually no need to tie the vein unless it is large or perforates the deep fascia. Make a transverse incision across the middle of the Now raise the leg high and slowly pull out the stripper popliteal fossa and deepen it through the deep fascia to attached to the vein out from the groin. Examine Dissect it out, ligating its tributaries, and trace the knee the groin wound for bleeding. Examine the avulsed vein end down into the popliteal fossa, and doubly ligate it for its length to make sure you have extracted it in toto; close to its communication with the popliteal vein. The anatomy of the short sapheno-popliteal junction is notoriously variable (35-5). Also, there may be incompetence may be in the anterolateral tributary short and long saphenous incompetence! Pass the prominent remaining superficial varicosities outside the stripper down this vein. Encourage walking as soon as possible for 1hr stripper in the same way from below, so that the daily. Advise wearing bandages proximal stripper upwards, following withdrawal of the for a further 2wks. If varicose veins recur, try sclerotherapy if the If the olive becomes detached, palpate where it has varicosities are limited. If the ulcer is not typically the result of varicose veins, consider alternative causes. A varicose ulcer is usually on the lower of the leg, especially just behind and above the medial malleolus. It may be of any size and shape, its edges are usually brown and eczematous, and it has red granulations under the slough on its base. Insist on bed-rest and apply (1) Sepsis with diabetes mellitus (causing a combination of frequent sterile water soaks until the ulcer is clean and vasculopathy, and neuropathy). Deslough the wound, and when clean, (2), Peripheral ischaemia due to arterial disease (usually apply betadine or zinc oxide paste. When dressings are no longer cumbersome, (3), Compartment syndrome due to burns, crush injury, apply graduated compression stockings from the base of snake bite especially with inappropriate tourniquet use, too the toes to the thighs. Then think of skin-grafting if the ulcer the diagnosis of gangrene is usually obvious; surface is granulating well (34. Make sure ischaemia is established: you may still save If bleeding persists or recurs, take the patient to theatre to toes, feet, fingers or arms if you release an eschar, expose and isolate the vein and ligate it formally. Look for xanthelasmata at the inner canthus of the eyes, indicating hyperlipidaemia, as well as the tell-tale signs of nicotine-stained fingers. If you have a Doppler ultrasound peripheries; strictly speaking, gangrene implies digestion probe, this gives greater sensitivity than the finger and can of dead tissue by anaerobic bacteria. If there is little lies, and if there is a stenosis whether there is a more subcutaneous fat, and no oedema, the skin becomes cold significant stenosis more proximally placed. The result is a mass of a patient will do better if you can arrange a successful infected, necrotic, smelly, partially destroyed tissue, revascularization of the limb and perform a minor known loosely as wet (or moist) gangrene. Every centimetre is useful; so is an elbow which he can use as a hook, and so is any Deciding where to amputate can be difficult. If the tissues have poor bleeding and the muscle is purple, There are a limited number of these, and the stumps for abandon this amputation level and go higher up. There are three technological grades of Consider a through-knee amputation in any frail and prosthesis; of these the third is not necessarily the worst. An emergency amputation for sepsis or crushed limb may, Do not despise these; when well made they last longer however, save someone from the jaws of death! Remember that the Many patients (particularly labourers and even some patient may be used to sitting on the floor rather than on a surgeons) hardly miss an amputated finger, for example. If you decide to amputate, discuss the decision carefully To this end, the Jaipur prosthesis is most suitable. If he is going to take a long time to It does not require any shoe: amputees can walk barefoot, recover, tell him so. It is made of waterproof material, difficult decision has to be made, let him share it. If he is involved in the decision, he is much more likely to It permits enough foot dorsiflexion and other movements be enthusiastic about subsequent rehabilitation. A leg prosthesis can: Fish mouth flaps must be long enough to cover the soft (1), have a cup to bear weight on the sides of the stump, tissues of the stump, but not be so long that their blood in which case the scar should be at the end. If the flaps are (2), bear weight on the end of the stump, in which case the equal, the scar will sit at the end of a stump. Higher up the vary in their scope and preferences, so visit your local one arm the scar can be anywhere. A good prosthetist can fit any on the kind of prosthesis envisaged: end-bearing, well constructed stump with a prosthesis. In the lower arm and leg, transverse scars are better than antero-posterior because they do not get drawn up between the two bones. After aguillotine amputation, though, you often need to revise the amputation by fashioning a formal stump higher up, as simply grafting the wound, or just letting it heal naturally rarely give a good result. Also, a guillotine amputation may not differentiate between healthy and septic or irreparably damaged tissue. Therefore, you will lose more length with a guillotine amputation as you need to shorten the bone again to be able to cover it with muscle and skin. The leg stump must be prepared for the prosthesis, and you need to teach the patient how to use it. Firm bandaging will hasten change of the stump from a bulky cylinder to a narrow cone, and exercises will strengthen the remaining muscles. After a lower leg amputation, for example, learning to kick a large rubber ball about is very therapeutic. Avoiding a flexion contracture of the knee is essential after a below-knee amputation. If there is already a tendency to flexion, keep the knee in a backslab or cast until full mobilization. Disarticulate a joint if you can, especially at the knee, because this will preserve its epiphyses.

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Once it has settled, it will allow you to inject Remember Helicobacter pylori is almost always present gastro-oesophageal varices (13-9), or inject around a where ulcers bleed, so use antibiotics (13. At this point you will the bleeding point may be difficult to find, and when you have to decide whether or not to operate in the hope of have found it, blood may obscure it, so that controlling it saving life. You will need a generous gastrotomy, bleeding outcomes (2, 3 or 4), described previously (13. Try to restore the blood pressure, but do not pour in so decide when your patient is more likely to die if you do fluids at one end only for him to bleed from the other end! Doing an operation which will prevent bleeding recurring Make a high midline incision extending up to the is a lesser priority, because you may be able to arrange for xiphisternum. Insert a deep retractor under the liver, so that your assistant can retract it Remember though that surgery should be a controlled risk upwards. Gently draw the greater curve of the stomach whereas further haemorrhage is an uncontrolled risk. If the patient is not suitable for surgery, or for part of the duodenum or a puckered, thickened, some reason you decide not to operate, do not give up: hyperaemic area on the stomach, especially on the lesser continue ice-cold saline/noradrenaline lavage. There may be nothing to feel if a posterior ulcer is eroding into the pancreas, or the liver. If this has not happened after 4hrs, Suggesting bleeding gastro-oesophageal varices: a firm abandon this method. If there is a duodenal ulcer, blood or hard, shrunken, irregular liver, and dilated veins on the may not be returned in the nasogastric aspirate, so you will stomach. If you find this, and there are no signs of an ulcer have to rely on the pulse and peripheral circulation to also, think about an oesophageal transection, and treat the know when bleeding has stopped. If there is no obvious bleeding site, feel every part of the If you decide to operate, open the stomach and stomach between your thumb and forefinger, and go right duodenum. Open the lesser sac ulcer, the simplest way to stop it bleeding is to undersew by dividing the greater omentum between the lower edge it. Perform a pyloroplasty: just remember not to close a pylorotomy longitudinally otherwise gastric outlet If you still cannot find the source of the bleeding, obstruction will result. Blood might be coming from anywhere from the duodeno the 2 common mistakes are: jejunal flexure to the caecum. Then check the colon for ileocaecal tuberculosis, carcinoma, amoebic colitis, and intussusception. If you have not been able to perform an that there is no bleeding from a post-bulbar ulcer. You may not be able to If you still cannot find any cause for the bleeding, see your way clearly because of a lot of blood clots in the try to pass the flexible endoscope through the duodenal stomach: in this case, unless there is continued massive opening distally. If this is unhelpful, or you are faced with catastrophic haemorrhage, open the stomach and duodenum. You have a choice of 2 incisions, depending on the degree of fibrosis of the duodenum: If the scarring and fibrosis of the duodenum is mild or absent, make a linear incision (13-12A) with of it in the stomach, and in the duodenum. If the scarring and fibrosis of the duodenum is severe, make a Y-shaped incision (13-12E). Make your linear or Y-shaped incision through the serous and muscular coats of the anterior wall of the stomach, starting 4cm proximal to the pylorus, and extending over the front of the 1st and 2nd parts of the duodenum for 3cm beyond the pylorus. If there is an ulcer, centre the linear incision on this, and make it about 1cm above the lower border of the stomach and duodenum, (13-12A). Use tissue forceps and a scalpel to make a cut through the mucosa of the gastric end of the incision, so as to open the. Enlarge the opening a little with scissors or stomach is slightly longer than that into the duodenum. Slowly cut through the remaining mucosa with incision open with stay sutures, held in haemostats, while you scissors. C, pull on stay sutures, so as to elongate or bleeding from the incision will obscure everything. E, if there is severe If there are too many haemostats, run a continuous layer of pyloric stenosis, which makes suturing in the transverse direction absorbable suture along each side of the incision, impossible, make a Y-shaped incision. Evert the mucosal layer with If you find a bleeding ulcer, control bleeding by Babcock forceps. Retract the edges of the V-shaped Place a deep retractor in the upper end of the opening in pyloroplasty incision. Using non-absorbable suture on a the stomach and ask your assistant to expose as much of its curved needle, pass 2-3 sutures deep to the ulcer, interior as he can. Ask your assistant to keep the area dry, and be sure to go Feel the inside of the stomach. You may see or feel: deep enough to include the walls and base of the ulcer, (1);An artery spurting from an ulcer on the posterior wall st but not so deep that you catch important structures, such as of the 1 part of the duodenum (the common site), nd the common bile duct. If the ulcer is in the distal duodenum, mobilize it, and make a small duodenotomy, and undersew the If you tear the oesophagus (which should never happen! If the bleeding point in the duodenum is obscured by First make sure bleeding is controlled as described above. The kind of pyloroplasty you should make will depend on the kind of incision you made, which in turn depended on If bleeding re-starts after the operation, manage this the severity of the fibrosis you found. If you made a linear incision, because there was only mild fibrosis, hold it open with stay sutures. Pull on these so as If you find what looks like a malignant gastric ulcer, to elongate it, and close it transversely with 2/0 absorbable adapt what you do to the size of the lesion (13. If the lesion is still and fix this across the suture line with a few sutures which bleeding, try a figure-of-8 suture with haemostatic gauze, pick up only the seromuscular layer. Leave an adjacent drain Consider first if, in your circumstances, a partial and a wide-bore nasogastric tube in situ. If you can operate gastrectomy might not be a better option, even if you have quickly, fashion a gastrojejunostomy (13-16); otherwise to refer the patient for this. If the spleen starts to bleed during the operation, They are usually multiple, shallow, and irregular. They usually give little pain, and severe bleeding is likely Pack around the spleen and wait to see if bleeding stops. Minor harmless gastric Then finish the rest of the procedure, and if there is no bleeding is common after an alcoholic binge. If further this kind may ooze severely, so that there are melaena bleeding ensues, depending on your experience, stools for several days. Treat with antacids hrly, and try a either replace the pack and perform a 2nd look laparotomy, noradrenaline in saline lavage (13. Exclude hypercalcaemia and the you need to devascularize the stomach by ligating both Zollinger-Ellison syndrome (gastrinoma, usually of the gastro-epiploic arteries as well as the left and right gastric pancreas). It presents as forceful bile-free vomiting, with constipation rather than diarrhoea, in a baby of about 3-6wks; the range can be 5days to 5months. To begin with the child vomits 1-2 feeds each day, but as the obstruction gets worse, the vomiting becomes more constant and more projectile. If he is not treated, he becomes dehydrated, alkalotic, hypochloraemic, hypokalaemic, and constipated; he loses weight, and becomes malnourished. Misdiagnosis is a tragedy, because surgery is not too difficult and is very effective. You should be able to feel the hypertrophied pylorus with warm hands as a smooth olive-shaped swelling in the right epigastrium. If you have difficulty, return a few minutes later, while she is still feeding him. If you are persistent, you should be able to feel it in all cases: it establishes the diagnosis. Ultrasound is a key diagnostic tool if you can interpret the images: muscle thickness should be >4mm and the pyloric channel length >16mm with failure of relaxation.

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Postoperatively, put the arm in a sling and encourage Incise the brachialis medial to the nerve and expose the active movements within the confines of the sling, or humerus. Define the line of the incision by You can expose the distal of the shaft of the radius by identifying the tendons of the palmaris longus and the approaching it from its anterolateral side. Incise just lateral to this is its proximal, which is covered by the supinator muscle (7-8B). If necessary, you can continue the incision Enter the forearm between the brachioradialis laterally proximally to include its middle. The radial artery lies between, or you may injure structures on the front of the elbow. You can approach the bone on Cut the deep fascia in the line of the skin incision. Distally, pronator quadratus covers the radius, that lie along the lateral border of the forearm: so you will have to divide it. Find the radial artery and vein, which lie between the lateral group of muscles and flexor carpi radialis. You will now have exposed the anterolateral surface of the distal of the radius. This will carry the muscular origins of the flexor carpi ulnaris anteriorly, and those of the extensor carpi ulnaris posteriorly. Cut straight through the vastus lateralis B, to expose the radius, enter the forearm between the brachioradialis down to the bone. The head and neck of the femur are and the two radial wrist extensors laterally, and the flexor carpi radialis medially. It and flexor carpi radialis flank the incision for the lower part this will need draining. Partly after Watson-Jones R, Fractures & Injuries, E&S Livingstone 1960, with kind permission. If this happens, the shaft of the femur the haemostat and the vessels at least twice. They are usually too deep into the wound to tie on the tip Prevent further slipping by applying skin traction up to the of a haemostat. If you are operating towards the distal end of the femur: (1) Do not enter the knee joint or the suprapatellar bursa. This will be easier than applying a medial plaster splint, which is the alternative. Later, use a hip spica or a plaster cylinder from the groin to the knee, add crutches, and encourage weight bearing. If chronic infection You can expose the femur by cutting straight down onto it along the lateral side of the thigh. A, prop up the buttock on a sandbag, and exists, do not operate before a firm involucrum has secure the patient on the operating table so he does not fall off! C, cross-section of the middle of need extensive reconstructive surgery to repair. A gap is particularly likely in the tibia, because so much of Kindly contributed by John Stewart. This extends from just distal to the greater trochanter to just above the lateral femoral condyle. Then cut straight through the vastus lateralis, down to the lateral side of the shaft of the femur. There will be some bleeding, but much less than there would be if you cut posteriorly on to the linea aspera. H-I, allow the edges of the flap to fall into the wound to close it postoperatively. Make the longitudinal part of the incision 1cm lateral to its Osteomyelitis of the fibula is uncommon. Proximally, do not extend it higher than involved, you can remove a sequestrum from the fibula as the tibial tubercle. If possible, avoid taking it across the soon as is convenient, without waiting for an involucrum tibia where this is infected, because the scar from the to form, because the tibia will support the leg. You can expose any part of the fibula by approaching it If necessary, curve its upper and lower ends to cross the between the peroneal muscles anteriorly and the soleus anterior border of the bone. The posterior tibial nerve and vessels are well Reflect the skin with the periosteum. If the head of the fibula is Incise the periosteum midway between the anterior and involved (rare) be very careful not to injure the common posteromedial borders of the bone. If the position of sinus tracks are medial, you can make a medial flap in the same way, with most of the length of the incision over the muscle on the medial side of the tibia. After you have removed the sequestrum: (1) If the tissues are not too tight, close the wound lightly and insert a drain in its lower part. Apply a posterior slab or a long leg cast with the ankle in neutral, and the knee in 20 of flexion. Mark a window in it while it is still soft, cut out the window with a knife, or with a plaster saw 2days later when it is hard. If you have left a deep trough in the front of the tibia which is slow to granulate and epithelialize, graft it. Apply a long leg cast with a walking heel, then encourage early weight bearing with as normal a gait as possible. If there is a very large skin defect in the tibia which is Approach the fibula between the peroneal muscles anteriorly, slow to heal, consider making relieving incisions about and the soleus posteriorly. Use the lateral position with the affected Hold them in place with sutures or strapping. Use the appropriate part of an incision which starts 5cm below the head of the fibula, and curves gently posteriorly If a large part of the tibia has been destroyed, and down towards the lateral malleolus. Reflect short skin inadequate involucrum has formed, try to get the fibula flaps anteriorly and posteriorly. Later, an of the fibula, because the common peroneal nerve winds operation in which a length of the fibula is moved across round it. The transposed piece of the If you are working on the middle of the fibula, incise fibula can hypertrophy greatly. The peroneal vessels are close to the medial involucrum had formed, or side of the fibula, so strip the muscles carefully. The calcaneus is a completely cancellous bone which Make a longitudinal incision exactly in the middle of the never forms an involucrum and seldom an isolated heel. You cannot remove it from inside its periosteum, so strip this away from the soft tissues of the heel and remove the bone completely, either as a single piece or in several smaller ones. Start in the midline, stay close to bone and reflect everything you meet medially and laterally. In this way you will avoid important structures, especially the plantar nerves entering from the medial side of the foot. Hold the ankle in a neutral position with a gutter plaster splint held with a crepe bandage. As the wound heals, start walking with crutches; later progress to full weight bearing. The edges of the scar will turn deeply inwards and split the heel into two cushions. If you apply a below knee cast and treat with an antibiotic for 3wks the infection will probably settle without surgery, but degenerative arthritis may follow. When sequestra do form in the skull, it is usually because a burn has destroyed the blood supply to the outer diploe. Split the heel for the easiest approach to the calcaneus; this brings no disability. Osteitis of the skull presents with headache, combined D, osteomyelitis of the right calcaneus with a sinus. If infection is limited to the pin track, opening up and (3) Frontal sinusitis (29. You can approach the calcaneus from either side in order (6) Pyaemia causing metastatic lesions in the skull.

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Recent changes in diet and management Abnormalities such as a very poor coat, evidence should be noted. Poor nutrition can give rise to a dull, of excessive self-grooming or large areas of alopecia dry, thin and brittle coat. Loss of condition may have may be seen from a distance, but the areas of the contributed to poor skin health which can itself then skin must be closely examined too. Specic points in the history of the patient examined, but in order to get a general impression may be useful. The stockperson may report frequent of the skin it can be assessed separately before the rubbing by the animal, suggesting pruritus. Details of previous treatment given and the response to such Visual appraisal of the skin treatment may also provide useful information. The environment of modern cattle, especially the the whole body surface is methodically inspected dairy cow, contains many features that may damage initially from a distance and then more closely, look the skin. The cubicles, the parlour and the oor may ing for areas of abnormal skin or hair which will later have abrasive surfaces or sharp corners that can be subjected to closer scrutiny. Such prob lick marks on their skin, especially over the ank lems in the environment are especially likely to be and shoulders. Repeated rubbing can lead to hair loss and thicken Pathological thickening of the skinoccurs in a number ing of the skin. Thick normalities, including swellings or discharging ab ening in the form ofcallus formationcan occur in areas scesses, should be noted for further investigation of skin, including those covering joints, which are later. Gangrenous changes in the skin and deeper tissue may have arisen through loss of circulation and may be seen or noted during Distribution of skin lesions manual appraisal of the skin. Lesions caused by photosensitisation are commonly seen in lightly pig Manual appraisal of the skin mented areas on the dorsal parts of the body which are exposed to sunlight. Such lesions are not nor this should involve as much of the body surface mally seen in pigmented areas. Ringworm lesions as possible, using caution when touching sensitive in calves are particularly common on the head and areas which might cause the animal to kick. Any abnormalities detected are Description of the skin lesions subjected to further scrutiny which may necessitate removal of hair and examination of the skin in good the clinician should try to determine exactly what light with the aid of a hand lens. Enlargement of abnormalities are present in the skin, which tissues lymph nodes may be detected at this stage (see are involved and how deeply the disease process below). The larger external any subcutaneous oedema or infection should also parasites such as lice may be seen at this stage. The average skin thickness in adult cattle is temperature, thickness, consistency and colour are 6mm, with decreasing thickness being evident from observed and compared with adjacent areas. The skin over presence of subcutaneous oedema or increased skin the brisket is quite thick and mobile. This area of skin turgor is noted: these abnormalities may be caused may have a spongy texture when compressed and by hypoproteinaemia or heart failure and dehydra may give an impression of subcutaneous oedema al tion, respectively, but they can also be the result of though it does not pit on pressure. When numbers of skin lesions are which does pit on pressure may be seen in this area found it is important to determine if they share the and between the mandibles in cases of right sided same aetiology. Self-inicted trauma can greatly modify and releasing it provides a general assessment of the ani mask the clinical picture. In a well hydrated animal involve some or all of the component structures of the pinched skin falls immediately back into place; in the skin: the hair, follicles, epidermal, dermal and a dehydrated animal the return to normal is delayed. Secondary Visual appraisal of the skin lesions are mostly non-specic and result either Manual appraisal of the skin from further development of the primary lesions Distribution of the skin lesions or from self-inicted damage. Examples of the Description of the skin lesions more common lesions in each category are listed below. Having identied the extent, distribution and type of skin lesions present, the clinician should try to Primary lesions identify the cause of the problem. They may show signs of excessive intact inner layers grooming, and hair loss will occur. In calves large numbers of lice may be seen all over family, the condition is characterised by subcuta the body surface and not conned to the dorsum of neous nodules and cysts along the backs of cattle in the neck and back as in adult cattle. Affected calves the spring and summer; careful opening of these may show no obvious signs of infestation, but a care lesions reveals the presence of warble y larvae. Micro Mange mites scopic examination of a skin scraping will enable Chorioptic, sarcoptic, psoroptic and demodectic the presence of lice and their egg cases to be con mange mites are found in cattle. Supercial skin damage mange cases), especially in housed cattle during the is caused by various biting y species. Caused by the surface living mite Chorioptes nodules in the skin can be caused by the bites of bovis, the condition is seen chiey around the tail ies including the species Haematobia, Stomoxys and head area of cattle where it causes crusty skin lesions Simulium. Rubbing by infested cattle produces sec urticaria in which prominent oedematous wheals ondary changes such as alopecia and thickening of rapidly develop in the epidermis and dermis, es the skin. Psoroptes infestation can lead to anaemia, and skin lesions on natalensis, the surface living causal mite, is asso the lower parts of the body are seen; there are small ciated with extensive thickening of the skin, pruritus areas of granulation tissue and possibly a hypersensi and hair loss over the shoulders, hindquarters and tivity reaction. Thickened crusty skin is seen in chronic cluding babesiosis, tick-borne fever and Lyme cases which may be in very poor condition. Demodectic mange is often asymptomatic in cattle, but the mite can be found in nodules in the skin cov Blow-y strike ering the thorax. Alopecia involving the skin of the this is initiated by the egg laying of blow ies, in neck but with no pruritus has been found in animals cluding Lucilia sericata or Phormia terraenovae, whose infested with the cattle itch mite Psorobia bovis. Diagnosis of mite infestation is based on the clini Blow-y strike can occur anywhere on the body, in cal signs associated with each mite and identication cluding the frontal sinuses exposed by horn removal. The larvae, which are readily seen with the naked eye, penetrate the skin and the deeper body tissues. The ticks may be found on animals imported from these areas and produce particularly severe symp Bacterial skin disease toms in animals which have had no previous expo sure to them. Local infection is frequently seen on the ears of calves a few days after the insertion of metal tags (less com monly after plastic tags). Pus is seen oozing from around the tag and there may be evidence that infec tion has invaded the cartilage of the pinna. This is a non-pruritic impetigo-like con dition often seen on the udder or perineum. A staphylococcal folliculitis is sometimes seen on the skin of the hindquarters of young cattle kept in unhygienic conditions. Pustules develop in hair follicles which can be squeezed to reveal their purulent contents. Dermatophilus infection this is occasionally seen, especially on the backs of cattle kept in crowded conditions where minor trau Figure 4. Hairs from the coat grow through the crusty lesions which are approximately 2cm across. Fungal skin disease Subcutaneous abscesses Ringworm is a very common disease, especially in these are very frequently seen in cattle and are most young cattle. Raised grey crusty lesions often associ ly associated withArcanobacterium pyogenesinfection ated with areas of alopecia are seen. Diag often very extensive and are palpable as uctuating nosis is by demonstration of fungal spores and my subcutaneous swellings around the tail head and celia in skin scrapings or broken hairs carefully other parts of the body surface (.

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The manipulation of this information can directly effect a change in the structural organisation of the nervous system through spatial and temporal summation and the facilitation of pre and post-synaptic inhibition. If two or more stimuli are pre sented and then reinforced together, associative learning can occur. This enables relationships in stimuli to be predicted and can link two aspects of motor behav iour occurring at the same time, such as hip and knee extension through stance phase in gait. There is a direct relation ship between the neural molecular form and functional performance (Kidd et al. The nervous system is continually undergoing modication based upon its experiences, and it is these modications which then support its role in achieving efficient and effective functional goals in a variety of environments. Neuroplastic changes following injury Any acquired brain injury will result in subsequent neuronal cell death, interruption of their axonal projections and potential cascade of degeneration to communicating 5 Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation neurons (diaschesis) (Cohen 1999; Enager 2004). The impact the lesion has on motor control and function will depend upon the location and the size of the lesion. The model of neuroplasticity provides evidence that the brain will respond to injury by reorganisation and adaptation aimed at restoring function (Stephenson 1993; Nudo 2007). There are three neuroplastic phenomena that occur in the nervous system following a lesion which facilitate structural and functional reorganisation (Bishop 1982; Kidd et al. These include denervation supersensitivity, collateral sprout ing and unmasking of silent (latent) synapses. Denervation supersensitivity occurs when there is a loss of input from other brain regions. An increased release of transmitter substance causes a heightened response to stimulation (Wainberg 1988; Schwartzkroin 2001). Post-synaptic tar get neurons become hypersensitive to the transmitter substance, increasing the number of receptor sites. Collateral sprouting appears in cells around the lesion, where collateral dendrites make connections with those synapses lost by cell necrosis (Darian-Smith & Gilbert 1994). Unmasking of silent synapses occurs when previous non-functioning neurons are accessed to form new connections (Nudo 1998; Johansson 2000). There has been increasing work demonstrating regener ation within the nervous system (Nudo 1998; Johansson 2000). Changes within the structure of the nervous system can be organised or disorganised producing adap tive or maladaptive sensorimotor behaviour, which can promote or be detrimental to recovery (Nudo & Friel 1999; Nudo 2007). Cortical plasticity Cortical representation areas have been found to be modied by sensory input, experience and learning, as well as in response to brain injury (Bruehlmeier et al. Cortical changes following injury include the loss of specic sensorimotor func tional representation with direct physical and functional consequences. Although not totally reversible, there have been numerous ndings demonstrating cortical plasticity and remapping following a cortical lesion. Where representation of an area has not totally been lost, the representation of the peri-infarct tissue and areas in axonal communication with the lesioned area, through axonal sprouting, have been found to take on representation and therefore function of the lesioned area (Rapisarda et al. Reorganisation has been seen in areas of the visual cortex which becomes associated with tactile tasks in blind subjects who read Braille (Sadato et al. Changes seen following peripheral lesions are based on the cortical response to changing input which can either be upgraded or downgraded, such as rema pping in subjects following amputation or selective anaesthesia, where there is a reduced representation of the affected area and an increase of representation of adjacent areas within the cortex (Merzenich & Jenkins 1993; Yang et al. The Bobath Concept explores this potential for cortical reorganisation through select ive afferent input to optimise internal representation and inuence movement con trol. Selective motor training or manipulation of the task, environment, or aspects of the individual as part of movement re-education also aims to promote plastic 6 Bobath Concept: Developments and Current Theoretical Underpinning changes. This has been seen in the cortical representation of the left hand, in a left handed string instrument player which when scanned shows greater cortical rep resentation compared with the left hand of a non-string player (Elbert et al. Enriched environments giving subjects greater than normal stimulation have been shown, at the right time, to promote signicant neuroplastic changes and improve ment in functional outcomes (Ohlsson & Johansson 1995; Johansson 1996). Emergent properties of each cortical area are constantly shaped by behavioural demands, driven largely by repetition and temporal coincidence (Nudo 2007). Such repetition drives motor cortical areas to form discrete modules in which the conjoint activity is represented as a unit, rather than fractionated and indi vidual muscle contractions (Nudo 1998). Skilled motor activities requiring precise temporal coordination of muscles and joints must be practised many times over and applied into everyday meaningful activities for optimal carry-over. Muscle plasticity Like neuroplasticity, the adaptability of muscle has been investigated extensively. Virtually every structural aspect of muscle, such as its archi tecture, gene expression, bre type distribution, number and distribution of alpha motor units and motor end plates, number of sarcomeres, myosin heavy chain pro le, bre length, mitochondrial distribution, tendon length, capillary density and muscle mass, has the potential for change with the appropriate stimulus (Dietz 1992; Pette 1998; Mercier et al. Skeletal muscle can be either conditioned or deconditioned depending upon the demands put on the muscle, and these can inuence properties such as strength, speed and endurance of the muscle. The range of muscle bre types allows for the diverse role and function of muscle needed to support human movement (Scott et al. It is the adaptabil ity of the proteins and the design of sarcomeres and myobrils which provides the basis for the modelling and remodelling of a large spectrum of bre types to match the specic requirements and altered functional demands (Pette 1998). Muscle bre phenotype is driven by neural activity and mechanical factors, a combination of stretch and activity (Goldspink 1999). Studies have shown that with an increased demand there is a shift from fast to slow bre types, an increase in size and number of mitochondria and an increase of the capillary density with an overall hypertrophy of the muscle (Mercier et al. With reduced demands or disuse there is muscle wasting due to decreased protein synthesis. This atrophy is more rapid in slow oxidative, pos tural and biaxial muscles with a slow to fast shift in bre type and a reduction in the capillary density (Mercier et al. Inactivity in a shortened position results in an increase in connective tissue, an increase in stiffness and resistance to passive stretch (Williams & Goldspink 1973). Muscles immobilised 7 Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation in a shortened position have been found to lose sarcomeres, with the remaining sarcomeres increasing in length to maximise tension in this shortened position (Grossman et al. Neurological lesions and the resultant neuroplastic changes have a signicant impact on the demands placed upon muscle. Early stages show an inability to achieve the execution of a voluntary command and leave the muscle in a position of inactivity and immobility (Gracies 2001). Muscles may receive an increase or loss of drive to the alpha motor neuron and its motor end plate, which will lead to a complex combination of conditioning and deconditioning. Where hypertonic muscles are immobilised in a shortened position the potential for a contracture develops with muscle atrophy, loss of sarcomeres, failure of actin and myosin cross-bridges to disengage, and accumulation of connective tissue (Watkins 1999; Gracies 2001). It has been found that even in the case of increased drive, however, muscles have been found to weaken due to insufficient motor unit synchronisa tion and decreased torque generated by the muscle (Gracies, 2001). Muscle imbal ance in compliance, length and strength will all inuence coordination for selective movement control. The main length associated changes interfering with function have been identied as a decrease in muscle length and an increase in muscle stiff ness, and it is these secondary musculoskeletal complications that are associated with poor functional outcome (Ada et al. Andrews and Bohannon (2000) identied that it is not only the hemiparetic side that presents with muscle changes but that the non-hemiparetic side also presents with muscle weakness compared to normal subjects. This highlights the signi cance of learned non-use in both hemiparetic and non-hemiparetic sides and high lights further the need for an individualised, holistic approach to the treatment of patients with neurological dysfunction (Hachisuka et al. The stages describe a progression through cognitive to automatic levels whereby the performance is rened and shows carry-over of learning (Wishart et al. This process demonstrates the developments in cortical representation for the learning of the new skill. Motor learning theories suggest that active participation, practice and meaningful goals are all essential for learn ing (Schmidt 1991; Winstein et al. There are numerous variables that are considered to be important determinants in motor learning which have been investigated using healthy individuals learn ing novel motor skills (Winstein 1991; Marley et al. These include: practice (amount, variability, contextual interference [order of repetitions such as blocked or random]); part or whole task; augmented feedback (frequency, timing, bandwidth [level of performance to be reached before feedback provided]); mental practice; modelling; guidance; attentional focus (goal attainment) and contextual variety.

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If they grow very large, the bowel may only be covered by peritoneum and skin, which may be paper-thin and adherent to the bowel itself. If they are long-standing, the rectus muscles may have separated widely, so that the abdominal contents flop outside the belly. The commonest lower midline incisional hernias are not too difficult to repair but often recur if the repair is not done carefully. Although recurrence is common, strangulation is not, so do not operate on these hernias unless you have to, especially if the hernia is large, and below the umbilicus. Note that this has occurred through the weakened area in the abdominal wall to feel through the linea alba above the umbilicus. This will fill the sac and show you If you find an epigastric hernia incidentally and it is small its true size. If you are experienced, you can sew in a mesh (best over the posterior rectus sheath layer (the sublay method): you can use sterilized mosquito netting. Do not put the mesh directly over the bowel (inlay method), because it may erode into the bowel wall and produce terrible fistulae. If there is infected intertrigo, prepare the skin with special care some days beforehand. While the abdomen is relaxed under anaesthesia, feel the margins of the defect carefully. Make an elliptical incision in the long axis of the hernia, wide enough to include a of the bulging skin, and extending 4cm beyond the defect at each end. Design the ellipse so as to remove the original scar and to produce a new one, without redundant skin or a tense suture line. Use sharp dissection to free the peritoneum, and the anterior rectus sheath, from the fleshy fibres of the rectus muscles, which are sandwiched between them. The posterior rectus sheath, which has often been missed out in the previous closure, may have retracted quite a long way laterally. Control bleeding, which may be troublesome, and try to repair the lower abdominal wall, layer by layer. Make flaps at either side, so that the skin and subcutaneous tissue (if there is any) are undermined for at least 4cm to allow for tension-free closure. Try to find a plane of cleavage between the peritoneum and the skin, without button-holing either of them. Undermining will be easier if you insert tissue forceps at the skin edge, and ask your assistant to exert traction on them, while you dissect the skin from the underlying sac. If freeing the ellipse of skin from the underlying D, open hernia sac at its neck. G, H, overlap in the centre of the sac, leave the ellipse attached to the anterior rectus aponeurosis. If you cannot overlap the aponeurotic layers, make parallel relieving incisions 10cm laterally into the Raise flaps of aponeurotic scar tissue from the covering of sheath only, but beware this is likely to be bloody, so have the sac on either side (18-23C) diathermy ready. The neck of the sac will probably be diffuse, and not easy If the defect is so large so that you cannot bridge the to define. Open it between haemostats, as for a laparotomy defect, you will need to suture in a mesh to close the (18-23D), and incise the peritoneum far enough to see if defect. You can use sterilized insecticide-free mosquito there are adherent loops of bowel. Free these adhesions netting; if you do not have any mesh; do not try to make a and the omentum (18-23E), and return the bowel and repair under tension. Put the mesh in under the rectus muscle, but over the posterior rectus sheath (under-lay method); you need to If you cannot easily free the bowel and omentum from dissect the rectus sheath quite far out laterally, inferiorly the fundus of the sac, leave them attached to it; and superiorly to secure the mesh, and this really needs free it from the skin, if you have not already done so, and diathermy. Check the viability Close the mobilized anterior rectus sheath, and advise of the bowel (11. You can put the mesh over the rectus muscle, Excise the redundant part of the sac. If these have been stretched and thinned out, trim these If there is a recurrent incisional hernia, repair is likely flaps away to leave a broad strip on one side, and a narrow to be very difficult indeed. If the pregnant uterus bulges through an incisional Otherwise, if they do not come together easily, hernia, consider doing the repair immediately after do not overlap them: you must avoid tension in your delivery, and tying the tubes. Take close small bites making sure If there is a persistent wound infection after a mesh you get a suture length-to-wound length ratio of 4:1, repair, remove the mesh. In this way, a double-thickness layer of fibro resect the affected portion of bowel as well as removing fascia will replace the linea alba. Stomas inevitably leave a weak area in the abdominal Insert a multiple perforated tube through a stab wound, wall, through which bowel may herniate either alongside let it lie under the flap, and attach it to a low-grade suction the stoma itself, or into the layers of the abdominal wall. Suture the skin edges, apply a firm pressure If the weakness in the abdominal wall is just a bulge, dressing, and do not disturb it until the sutures are to be owing to weakness of the muscles themselves, removed. If there is a true bowel with cut strip tied or overlapped and pinned around the herniation, you will probably need to re-site the stoma and abdomen) will provide physical and psychological support. Teach supporting of the Perform a formal laparotomy; start by mobilizing the wound by pressing the hands on the sides of the abdomen. The lumbar incisional hernia found after operations on the kidney through the flank, however, rarely needs repair. Europe and North America (population 800 million) only Existing programmes to prevent mother-to-child 1000. However, much higher while shopping, but includes a crash with an ambulance estimates have been reported globally and in individual during referral for complications in pregnancy. To facilitate the identification of maternal deaths in Maternal deaths happen in <50% cases at home. Most die in a health institution where pregnancy-related death, which is defined as the death of they might have arrived moribund. Much dying also a woman while pregnant or within 42days of termination happens en route. Most die on the day of delivery or in the of pregnancy, irrespective of the cause of death. The 2 delay Sub-Saharan Africa, 1/16 relates to physical, cultural, and financial constraints as Northern Europe, 1/25000 well as the security situation. The third delay relates to the time needed to organise and pay for the actual medical care. In some communities in Africa and Afghanistan it is still Saving pregnant women is not basically a question of 1, 000 or more, which means that a mother has around a having beautiful machines, laboratories and computer. The result is that a woman living in a were better than they are in many large African hospitals remote area of Afghanistan has a 1, 000 times greater now. At that time the Caesarean Section rate lifetime chance of dying of a pregnancy than a woman in was <1%. One of the oxytocin, anti-D and anti-tetanus injections, problems apart from war is that in certain countries, prostaglandins, contraceptives other than condoms, authorities discourage (higher) schooling of women, cardiotocographs, ultrasound, or Doppler machines, as was the case in Europe 100 years ago, and male doctors or modern suture materials. There was little evidence are forbidden to attend to pregnancies, as in Europe 400 based knowledge. The difference was that the those of their children, because a good basically equipped facilities were provided and there were enough staff. The exodus of hand, reducing infant and under-five mortality by means of staff for more lucrative jobs was rare and they were vaccinations, provision of clean water, improved nutrition revered for identifying with the suffering of their own is less of a technical problem. So encourage such staff, and do what you can to successful building a district hospital, including its staffing improve their working conditions! This is related usually to traditional women and services at 3 levels: in the community, customs and beliefs. Especially, it needs plenty of near every good district hospital might prevent much well-trained midwives.

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C, Trendelenburg test for the long communicating veins between the superficial and deep saphenous vein: lay the patient supine and raise the leg. Apply a systems, have had their valves destroyed by thrombosis: venous tourniquet just below the saphenous opening. D, if the femoral valve is ulceration is more common, and treatment more difficult. F, anatomy of the Varicose veins are generally associated with Western veins of the leg; the long saphenous enters the femoral vein through life-styles; obesity and low-fibre diets play a role. G, close-up view of a varicosity, and an incompetent perforating vein connecting it with the deep venous They are unsightly and cause aching and cramps, a scaly, system. To test the competence of the valves of the short saphenous vein, lie the patient flat and apply 2 tourniquets, one above the knee to occlude the long saphenous vein and another just below the popliteal fossa to occlude the short saphenous vein. Ask the patient to stand up, leave the upper tourniquet on, and remove the lower one. If the blood flows immediately into the short saphenous vein from above, the short saphenous valve is incompetent. Examine the patient standing in a good contrast: you may cause the thrombosis you want to avoid! Feel for a thrill in the vein above as you tap it below, Suggesting primary varicose veins: usually start at and listen for a bruit of a (rare) arteriovenous fistula. Incompetence demonstrated by back-flow If there is ulceration, thick induration, and marked on release of the upper thigh tourniquet (long saphenous), hyperpigmentation, the valves of the deep veins are or just below the popliteal fossa (short saphenous). Suggesting secondary varicose veins: obesity, multiple Perform the Trendelenberg test: pregnancies, or a pelvic tumour; a history of venous thrombosis, an older age, less obvious veins partly hidden To test the competence of the perforating veins and the by eczema, fat necrosis, or ulceration. Try to fit graduated compression stockings from the distal metatarsals to thigh or calf If the veins fill rapidly from below, the varices are being (depending on whether long or short saphenous system is filled from the deep veins, and the valves of the affected). If you inject sclerosant into an artery, you may cause extensive gangrene, so do not inject around the ankle. Ask the patient to stand up, observe, palpate, and percuss the veins; mark them with a permanent marking pen. Then ask him to lie down, elevate the foot, and feel the course of the veins for gaps in the fascia (sites of incompetent communicating veins). Press with the tips of your fingers on as many of these gaps as you can, and, still pressing, ask him to stand. If removing your finger from a gap in the fascia immediately causes the vein to fill, that gap is the site of an incompetent perforating vein. Ask him to sit on a couch with the affected leg over the edge of the bed so that the vein fills, insert the mounted needle at the marked sites c. Apply a pressure pad over the injection site to keep the vein empty, and apply a crepe bandage up to that site. Apply a graduated compression stocking over the bandage E, elevate the leg and inject the sclerosant, starting from the site and immediately encourage walking for 1hr, and thereafter nearest the foot and apply pressure. Advise elevation of the legs as much as Kindly contributed by George Poulton possible. If there is severe pain after the injections, take off the (3) Varicose veins which persist or recur after stripping. You often come to tributary veins of the saphenous sapheno-popliteal incompetence. If a patient is on oral contraceptives, saphenous vein and demonstrate the sapheno-femoral she should stop them one month before operation. Clamp the saphenous vein a suitable distance from the femoral vein with haemostats and divide it. There may be a saphena varix, a dilated saccule below the incompetent valve; you will need carefully to get above this to ligate the vein satisfactorily. If you encounter much bleeding, do not clamp blindly with haemostats, or you may damage the femoral vein, or even the femoral artery. After 3mins pressure you can usually find the bleeding point and control it, either with a haemostat or a fine silk stitch. Then mobilize more length of the saphenous vein down the leg; place an untied ligature round it and holding one edge of the vein carefully with dissecting forceps, release the haemostat. If there is too much bleeding from the open vein (because the patient was not put in head-down tilt), re-apply the haemostat further down the leg. Removing a limb by amputating through the shaft of a bone produces an effect which varies with the site. Delayed primary closure is always wise: (1) if the limb is already infected, or may soon be so. If you decide on delayed primary closure, cut the flaps long, to allow them to retract. Leave the muscle and fascia unsutured, bandage the skin flaps over dry gauze swabs, do not put in any sutures, and inspect the wound 3-5days later. If it is infected, debride it and leave the flaps open for 1-2wks, and close it only when it is clean. The long posterior flap technique is the standard for the If necessary, you can use any sterilizable saw or domestic knife. The back of the saw stiffens it during the early part of the cut, but can be In the leg, equal anterior & posterior, or lateral flaps are hinged back later to let the saw pass through. A Gigli bone saw is a piece of wire with sharp teeth on it which you pull to and fro between two handles. In these cases, you need not worry so much about ischaemia and can use a tourniquet, but do not exsanguinate the limb with an Esmarch bandage (3-6L) where there is sepsis or malignancy. Release the tourniquet before you suture the muscles, so that you can tie any bleeding vessels before you cover them. For ischaemic limbs, try to use epidural anaesthesia, which causes vasodilation and improves peripheral blood flow. For equal flaps, make the length of each flap equal to of the diameter of the limb (35-8A). For unequal flaps, make the longer flap equal to the diameter of the limb, and the shorter one equal to its diameter (35-8B). As a general rule the combined length of both flaps should equal 1 times the diameter of the limb at the site of the bone section. Cut through the skin down to the deep fascia, and reflect this up with the skin as part of the flap. Minimize trauma to the flaps: handle Together, the flaps should be 1 times the diameter of the limb. C, reflect the skin with the deep fascia and cut the muscle 8cm distal to the bone section. E, the deep fascia closed over the bony trim them if they are too long later, but you cannot stump, protecting it with muscle. Cut the flaps as far distally as you can, so that you can (4), Make sure the scar is not at the end of the stump if that refashion them later. Cut the skin down to the deep fascia limb will carry the pressure of a prosthesis. Cut them long enough stump with vaseline gauze, betadine and plenty of dry for this but do not leave so much muscle that the stump gauze. Leave them a little longer if you are using delayed primary closure, because they will have more time to shrink. Use a long sharp amputation knife or kitchen knife to cut the muscles straight down to the bone. Do not use a scalpel which makes many small cuts, and leaves shreds of injured muscle. If the muscles look unhealthy when you cut them, abandon the operation at that site, and amputate higher up.

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This has been shown for both men and women and in various ages, as well as in women around meno pause. With the new knowledge that indicates that oestrogen replacement therapy does not 192 physical activity in the prevention and treatment of disease reliably protect against heart attack (19, 20), this knowledge about the effects of exercise becomes even more important. In addition, exercise improves aerobic fitness and endur ance, which hormone treatment does not do (59). Thirty minutes of physical activity at a moderate intensity (sweaty or breathless) reduces the risk of premature death in other wise inactive persons (60). All activities that involve major muscle groups and are dynamic and rhythmic by nature (cycling, brisk walks, aerobics, etc. The studies claim that this was not only due to the physically active women being generally more aware of health. The cause of these findings can possibly be that more intensive exercise can thin out or completely prevent ovulation, which means that oestrogen production is lower and the risk of breast and uterine cancer thereby decreases. Other proposed causes of a reduced risk of breast cancer in physically active women is that exercise also activates antioxidative systems (65), reduces breast density measured by mammography (66) and decreases oestrogen levels (67). In summary, regular physical activity entails many advantages for menopausal women. The majority of the effects do no differ from those also observed in people of other ages, but the effects are clear and affect several of the phenomena that otherwise usually become prevalent in menopause in particular. One should choose varied types of exercise to avoid overload problems from excessively one-sided exercise. It is also important that the activi ties chosen are perceived as pleasant and enjoyable and that one gladly exercises and trains in a group. It is necessary that these activities continue regularly and are maintained for an extended period of time. Indications Physical activity during menopause can serve as both primary and secondary preven tion, in other words can both prevent problems from arising and function as treatment once something has happened (such as an osteoporotic fracture). The treatment is prob ably nonetheless most effective as primary prevention, since the problem developed can in itself reduce the possibilities of pursuing regular exercise. The effect of physical activity in many cases reinforces the effect of hormone therapy and there is absolutely no obstacle to combining these measures. The need is most clear among women who do not choose hormone therapy (primarily with regard to the effect on bone density) and physical activity can also continue for an unlimited period, which is not true of hormone therapy. Menopausal women can follow general exercise principles (also see Chapter 2) for adults that mean that one should do at least 30 minutes of moderate physical activity per day (one will be able to talk but not sing, i. A combination of moderate and intense activity can also be utilised to achieve these effects. Moderate activity can also be divided up into multiple sessions per day, such as 3 x 10 minutes (69). The intensity of the exercise, the number of sessions per week and the time for every session should be gradually increased for a tentative minimum of three months to not lead to overload symptoms. The exercise can gladly be performed as group training and with varying content to increase the chances of the activity becoming permanent. Suggestions of suitable activities Brisk walks, Nordic walking, dance, aerobics, step-up training, exercise callisthenics, strength training, cycling, jogging and skiing are excellent activities. Swimming is a good activity that stimulates the muscles and fitness, but does not have any effect on oste oporosis. Strength training can be done at home, under guidance at a training centre or as general group training to music. Contraindications There are no contraindications except in acute illness with a diminished general state of health. Risks the risk of injury in excessively intense and rapidly increasing training must be observed, which is why intensity, frequency and duration should not be increased too rapidly, but rather gradually and with caution. An excessively rapid increase could cause a risk of overload symptoms, which can take a long time to heal and thereby make exercise difficult for a long period of time and, which is perhaps most important, could mean that the woman would not dare to continue or resume her training. Concentrations of calcitonin gene related peptide and neuropetide Y in plasma increase during flushes in postmenopau sal women. Effects of estrogen therapy on well being in postmenopausal women without vasomotor symptoms. Report from the Standardisation Sub-committee of the International Continence Society. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Disturbances in postural balance are common in postmenopausal women with vasomotor symptoms. Oral oestrogen replacement therapy versus placebo for hot flushes (Cochrane Review). Vasomotor symptoms and qual ity of life in previously sedentary postmenopausal women randomised to physical activity or estrogen therapy. Physical activity and risk of vasomo tor symptoms in women with and without a history of depression. The importance of continued exercise participation in quality of life and psychological well-being in previously inactive postmenopausal women. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work Moderate exercise does not enhance the positive effect of estrogen on bone mineral density in postmenopausal women. Estrogen therapy and variable-resistance weight training increase bone mineral in surgically menopau sal women. The effects of physical activity on menopausal symptoms and metabolic changes around menopause. The effects of hormone replacement therapy and resistance training on spine bone mineral density in early postmenopausal women. Effects of balance train ing in elderly evaluated by clinical tests and dynamic posturography. The independent effects of exercise and estrogen on lipids and lipoproteins in postmenopausal women. Brisk walking and plasma high density lipoprotein concentration in previously sedentary women. Physical fitness and incidence of hypertension in healthy normotensive men and women. Is the body fat loss a determinant factor in the improvement of carbohydrate and lipid metab olism following aerobic exercise training in obese women Physical activity duration, intensity, and arterial stiffness in postmenopausal women. Effects of different doses of physical activity on cardiorespiratory fitness among sedentary, overweight or obese postmeno pausal women with elevated blood pressure. Oslo: Statens rad for ernaering og fysisk aktiv itet, Norwegian Ministry of Health and Social Affairs; 2000. Lipid peroxidation and the protec tive effect of physical exercise on breast cancer. Physical activity, body mass index, and mammographic density in postmenopausal breast cancer survivors.

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A larger pelvis after the symphysiotomy for a problems, most of which are interrelated: dead baby could help with the next delivery. A difficult vacuum extraction may tubal ligation is performed together with a Caesarean succeed, but only after prolonged traction and the risk of Section. Symphysiotomy will make delivery (5) Abnormalities of the maternal pelvis or legs. A large foetus >4kg as estimated by the fundal height there are any signs of foetal distress, it is ideal. A foetal head which remains >3/ above the pelvic brim Section, and it avoids a difficult vaginal delivery. If the foetal head is deeply jammed into the pelvis, perhaps Relative contraindications are: with caput visible at the vulva, symphysiotomy will be safer. Record the complications, and not only those around the index delivery but also from subsequent deliveries, say over the next 10yrs. In order to avoid a Caesarean Section, but could have had a symphysiotomy for failed damaging the vagina, or urethra (which you are pushing to vacuum extraction, or for failure to progress or foetal distress in the nd the side with your index finger of your non-dominant hand), 2 stage, die of complications of a subsequent delivery or become infertile because of postoperative peritonitis. There will then be evidence to stop cutting downwards, but swing the blade towards you, challenge inappropriate use of Caesarean Section in your region. Check the cervical dilation, the descent and position of the the sharp part of the blade will cut the fibres of the lower foetal head. Re-insert the knife through the stab wound try to insert a finger vaginally between the foetal head and and now swing the blade away from you, thereby cutting the pelvis. Often, though, you will not have cut enough fibres and will Listen to the foetal heart to make sure that the foetus is alive. If they allow the legs to flop apart, the fibres of handle up and down somewhat in a 20 rocking action the sacroiliac joint may rupture, and the patient will have against pressure of your finger in the vagina. You will value these assistants anyway, even if you have reliable lithotomy poles, to prevent too much abduction. If you cut 90% of the fibres that is enough; do not be Palpate the bony margins of the symphysis pubis. You may need to push Be careful not to do exert too much rotating force on the the foetal head a little to pass the catheter. However it is Place your index finger (do not use two fingers, because the usually easy to retrieve a large blade. You will find anyway that most of your symphysiotomies Use a large blade, preferably a solid knife, so that the blade will be done after a failed vacuum. Make a 2-3cm incision in the sure, where there is an indication for symphysiotomy, skin and subcutaneous tissue over the symphysis pubis in the that an extraction will fail. Always keep the urethra to one side with your 3rd day, replace it and try again on the 5th day. Do not cut above the symphysis pubis, because the uterus If there is incontinence of urine, it may be: or bladder may be protruding there. Do not cut below the symphysis pubis, in case you weeks after operation but will usually recover spontaneously damage the clitoris. Make sure the legs of the patient are held firmly in situ: it might close or at least the hole might become position, and strapped together before moving her from the smaller. Do not apply delivery forceps after only occurs when the incision involves bone, so keep strictly symphysiotomy; they may stretch the sacroiliac joint too to the midline in the fibrocartilage of the joint. If the patient has difficulty walking with an uneven gait, If the incision continues to bleed, suture the subcutaneous this may well be because her hips were not held firmly, and tissue, and skin with 1-2 vertical mattress sutures. Leave a self-retaining catheter in place for as long as the If you injure the urethra, see 21. Normally after 2days when she is able to sit on the side of the bed, remove the catheter, provided the 21. The usual cause of this is obstructed labour or a balloon blown up still partly in the For an obstructed labour with a dead baby a destructive urethra because the foetal head prevented it being passed all operation is usually better than a Caesarean Section. These operations are sometimes said to be old fashioned, and to have no place in modern obstetrics. Old-fashioned If the indication was for prolonged obstructed labour perhaps, but they have some useful features: (>6hrs), the patient is at risk of developing a fistula; so (1) They need few instruments and only simple anaesthesia, leave the catheter in situ for 10days to try to prevent this so that they can be done in a health centre where a woman is from developing or to help a tiny fistula close completely. If referral is difficult, they avoid the risks and delays of a Apply a stretch bandage around the knees for 2days. Allow walking with the help of a chair, frame or trolley as (2) They leave the mother with an intact uterus, which will soon as the legs can move independently without pain be less likely to rupture if she has a home delivery the next (usually 72hrs). Most patients are walking than Caesarean Section to spread the infection into the well, and fit for discharge, on the 10th day. She If spontaneous delivery does not occur, pull with the may not be fully grown when she first becomes pregnant, so vacuum extractor. Use oxytocin with the birth of the anterior that the pelvis is small and the first labour obstructs. Besides their distasteful If the wound shows signs of local infection, use ampicillin messiness, the main argument against these operations is or chloramphenicol, which are not passed through breast that, in inexperienced hands, they are liable to be even more milk as are tetracycline or sulphonamides. If there is postoperative fever, suspect urinary or puerperal To those who decry them, we reply that as long as there are infection because of prolonged labour, or both. There are several types of destructive procedures, each with its own indication: (1) Craniotomy, (2) Decapitation, (3) Cleidotomy (cutting the clavicles), (4) Thoraco-abdominal evisceration (or embryotomy) A transverse lie requires decapitation, and often evisceration also, which is more difficult than craniotomy; but even so, it is often wiser than Caesarean Section, which is particularly dangerous for an infected neglected transverse lie. If a multigravida has been in labour for a long time, the lower segment will be very thin, and if it is tender and distended, it is extremely thin. Any destructive operation, except pushing a needle into a hydrocephalic head, will rupture the uterus. Always perform a destructive operation in the theatre with a laparotomy set ready for immediate use. You need this, either immediately instead of a destructive operation, if you find that the indications are unsuitable, or immediately afterwards, if you discover that the uterus has ruptured. Put your fingers through the cervix to rest against the foetal Use the lithotomy position, and clean and drape the vulva skull. For a hydrocephalic head, you only need a large bore the skull, open the instrument and rotate it 360 to break cannula to drain off the fluid for the head to collapse. Brain tissue will flow out from the perforation; the foetal skull will now collapse. If a piece of the foetal skull pulls off, reattach Put one hand into the vagina and support the fundus with the the forceps taking a deeper bite of skull closer to its base. Examine the condition Make an episiotomy if indicated and deliver the remains of of the lower segment; explore it as far as you can without the foetal head. Where exactly are the foetal head and (1) Do not include folds of the vaginal wall or cervix. Do not try an internal version without doing an If delivering the foetal shoulders is difficult, put a hand evisceration first: you will rupture the uterus. If you cannot bring down the foetal shoulders by turning, bring down the foetal arms one by one. Put a hand Bring a foetal arm down or pull on a prolapsed arm with one behind the foetus in the vagina and feel for the foetal hand, and apply a weight connected to the arm; if you can posterior arm.

References:

  • http://www.health.ny.gov/environmental/investigations/hoosick/docs/cancer_report.pdf
  • https://www.foundationforwomenscancer.org/wp-content/uploads/FWC-Endometrial-Cancer-Your-Guide.pdf
  • https://www.brookings.edu/wp-content/uploads/2017/08/casetextsp17bpea.pdf
  • https://www.fda.gov/files/vaccines,%20blood%20&%20biologics/published/Package-Insert---Menactra.pdf

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