睿学教育Wisdome Education

Amit Khera, MD, MSc

• Director, Preventive Cardiology
• Assistant Professor
• Department Inernal Medicine/Cardiology
• UT Southwestern Medical Center
• Dallas, Texas

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When I was as after-care (a truth that must be declared loudly very young antibiotic 2014 buy genuine trimethoprim online, Robert Jones said that it would be when some socialist ministers of health belabor wise for me to visit European orthopedic centers us on the need for preventive as opposed to cur- and see the work of surgeons in other countries bacteria plague inc generic trimethoprim 480 mg on line, ative medicine) anabolic steroids discount trimethoprim 960 mg on line. This skilled operative technique, and my reply was that much as I would like to , I superb organization, and happy spirit of recovery could not afford it. Nothing more was said, but was applied so generally to all the hospitals of this some weeks later he called for me and said that country that it would be invidious to try to enu- in rewriting his book on orthopedic surgery he merate them. Indeed there was no orthopedic wanted a complete study of the literature on pes center or great teaching hospital that Jones did not cavus and pointed out that this would mean trav- influence. Having done it and presented to 1947, he was nominated to the first orthopedic him the review (which in fact he never wanted— teaching post to be created in France in 1953. Before long it was to become typical of the disarming generosity of Robert a service in orthopedics and traumatology with Jones to young surgeons. Robert Judet was On June 28, 1957, there was a service in the appointed Professor of Orthopedics and Trauma- Cathedral of Liverpool, on the centenary of the tology in 1963. He was a member of many birthday of Robert Jones in 1857, near the foun- national and international orthopedic societies, a dation pillar in which are laid his ashes, the first Corresponding Fellow of the British Orthopedic ever to find a resting place here, above which is Association and a member of the American a stained glass window dedicated to Service. As Orthopedic Association and the American long as the walls of that great Cathedral stand, Academy of Orthopedic Surgeons. His first thesis, at the age of 21, was generosity, with kindness and joy of heart. During his career hearts and minds of those who came within the he studied subjects as varied as the repair of warm glow of his presence, and who learned pseudarthroses, pedicle bone grafts, quadriceps humbly to love him, his spirit still lives. With his brother, Jean, he was the first to use an acrylic prosthesis to replace the femoral head in 1946 and presented the results of the first 400 cases at the meeting of the British Orthope- dic Association in 1951. Undaunted by subse- quent failure that resulted from the reaction to the wear of the acrylic material, he continued to work and experiment in this field, developing with his son Thierry a cementless total hip arthroplasty in 1971 and reporting the results of the first 828 cases to the British Orthopedic Association in 1975. It is said that even at the age of 70 he could operate on two hips before breakfast. New approaches and fresh ideas flowed ceaselessly from him: indeed it was said that any assistant who went away on holiday found himself out of date with his chief’s current thoughts by the time he returned. The yearly orthopedic 1909–1980 courses that he instituted at Garches became famous throughout France and abroad. He was an Born in Paris in 1909, the son of an orthopedic impeccable operator. His knowledge, ability and surgeon, Henri Judet, Robert studied as a medical manner inspired confidence in his patients. As a man, he was the epitome of he worked in general surgery but soon, under the Gallic qualities—charming, generous, entertain- influence of his father and his elder brother, Jean, ing, discerning and the perfect French host. His he came to work exclusively in orthopedic exploits in the Second World War and in the surgery. Appointed Chirurgien des Hôpitaux in Resistance (he was arrested by the Gestapo but 167 Who’s Who in Orthopedics fortunately was freed for lack of proof of his clan- Eventually his work was recognized, and he destine activities) earned him numerous decora- became attending orthopedic surgeon and ulti- tions, including the Chevalier and Officier de la mately chief of the Department of Hand Surgery Légion d’Honneur. American Board of Orthopedic Surgery in 1936, and subsequently served as examiner of the board for a number of years. He was a fellow of the American Academy of Orthopedic Surgeons and was further honored by election to the American Orthopedic Association and the American Society for Surgery of the Hand. Kaplan’s scholarly pursuits, which resulted cumulatively in more than 100 major medical papers and four seminal books, were based on detailed human anatomical investigations, com- parative anatomical dissections and studies, and his passion for language. His creative human anatomical pursuits were conducted at the College of Physicians and Surgeons, Columbia University, where he was clinical associate pro- fessor of anatomy until his mandatory retirement in 1963. His comparative anatomical studies were conducted at the New York Zoological Gardens (the Bronx Zoo) and at the American Museum of Natural History. As a result of these studies, he published many classic scientific papers, which even today remain a font for the contemporary Emanuel B. His lifelong love of language was 1894–1980 reflected in his writing, teaching, and conversa- tion.

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Robert Jones qualified in medicine in 1878 infection under tooth generic trimethoprim 960 mg buy on line, and gained the Fellowship of the Royal College of Surgeons of Edinburgh in 1889 antibiotic blue capsule cheap trimethoprim 480 mg mastercard. He was soon appointed general surgeon to the Liverpool Robert JONES Stanley Hospital and antibiotic resistance review cheap 960 mg trimethoprim with amex, while still a young man of 1857–1933 30 years, general surgeon to the Royal Southern Hospital of Liverpool. This broad surgical expe- The kindly word, the encouraging smile, the twin- rience stood him in good stead in later years, kling eye with creases all going up in the right when his abilities were applied to that part of direction, and the whole magnetic personality of general surgery concerned with disorders of the Robert Jones, seem as vivid today as they were limbs and spine—orthopedic surgery. He was of 30 years ago when he was at the peak of his course strongly influenced by his uncle Hugh endeavor in creating and establishing the princi- Owen Thomas, to whom he was apprenticed at 11 ples, science and art of orthopedic surgery. Nelson Street—the house that became a Mecca Perhaps his greatest contribution was to the art of for surgeons from all over the world. We have surgery because he taught us all to be so infec- said that Hugh Owen Thomas was descended tious in our happiness that disabled and distressed from a long line of Welsh bone-setters; but even patients also became happy. I never knew a more his father Evan Thomas, unqualified as he may joyful man with his quips, pranks, jokes and have been, treated thousands of patients not only beaming smile, so that when he went to from the industrial north of England but from 164 Who’s Who in Orthopedics every corner of the globe. Robert Jones could London, though always maintaining his free hardly have escaped this traditional influence, or Sunday clinics at Nelson Street. But before he did the powerful personality of his uncompromising so, his alliance with Agnes Hunt had been created uncle, who battled and fought continuously in and firmly established. She had first brought chil- favor of safe and conservative treatment as dren from her derelict country home at Baschurch opposed to unsafe, sometimes wild and often in Shropshire, where stables had been converted dangerous operations. So every Saturday she a wrench concealed beneath his coat-tails to would arrive in Liverpool with two or three correct a recently malunited Colles’ or Pott’s frac- perambulator-loads of crippled children for ture before the patient had time to breathe or Robert Jones to operate upon, and take back a wonder what it was all about; and here it was that similar number of loads to Baschurch. From this Robert Jones learned not to waste time, and to very simple, undignified, perhaps illicit, some- know the great possibilities of conservative treat- times naughty, but always happy and joyful activ- ment. This famous house, having been visited by ity, there developed the great hospital at Gobowen surgeons from throughout the world, who, like the in Shropshire, now the Robert Jones and Agnes Mayo brothers, intended to stay for a day but Hunt Orthopedic Hospital, which with its after- found themselves magnetized for a week, was care clinics serves ten or more counties, most of destroyed by a time-action bomb in the Second the central part of England and Wales, and World War. Fortunately, the stone above the receives patients not only from all parts of this doorway chiselled “H. It was the recovered from the debris and is preserved in the first hospital ever to organize so complete a Hugh Owen Thomas and Robert Jones Library in service—preventive, curative and securative— Liverpool. I, for my sins, having paid some sort first seeking out miserable children who had for- of pilgrimage several days after the raid, stole merly been locked away in hamlets because the some of the broken tiles from that famous corri- crippling had been thought to be a visitation from dor—and I still treasure those fragments. God, bringing them to the hospital for treatment, With this background Robert Jones was versed following up the after-care in their homes, and in the principles of manipulative and conservative then training the disabled in trades, occupations treatment, often uncompromisingly antagonistic and recreations by which to make them self- to the accepted teachings of that day; but to it he supporting men and women. Here again, at what was then the Shropshire Thus he became one of the founders of modern Orthopedic Hospital, but is now the Robert Jones orthopedic surgery. Quite soon his operating and Agnes Hunt Orthopedic Hospital, he would lists at the Southern Hospital, varying in length undertake incredibly long lists of operations, from 20 to 30 operations, starting at 2 o’clock never less than 20 and often as many as 30. These endeavors have occasionally been a few cases of cleft palate, nephropexy or salpin- described since then, rather disparagingly, as gitis put at the end. These were left more and “marathons of surgical exploit”; but this belittles more to Theodore Armour, who probably did not and quite fails to understand the skill of organi- mind starting at seven or 8 o’clock at night zation, and the skill of operative technique, that because he never knew one hour from the other, made it possible. Certainly the also of the extensor tendons on the dorsum of the most dramatic was the vast organization he devel- feet and the flexor tendons at the interphalangeal oped during the First World War, when the loyal level—a technique that is being forgotten; and endeavors of American and British surgeons were while those feet were having plaster-of-Paris fused so happily. It may be true that Lieutenant- applied to the tips of the toes to maintain correc- Colonel, soon Major-General, Robert Jones was tion of the clawed toes as well as of the clawed quite likely to walk down Bond Street with his feet, a subtrochanteric osteotomy was being done general’s cap worn inadvertently back to front; he to correct flexion–adduction deformity of the hip was a terrible soldier; but he was a wonderful joint; and while the abduction frame with skin- friend. What more can of the staff with Robert Jones and the chiefs, the we say? We can say much more, and this is what house surgeons, theater sisters, nurses and order- matters most. He was a mild, lovable, under- lies—most of them seriously crippled themselves. Bernards If you are as breathless in reading that sentence and Irish wolfhounds; he enjoyed boxing, and as I am in writing it, you are not half as breath- how strenuously he boxed himself; he was fond less as we all were in sharing the magnificent of cricket; he loved children, who soon learned to organization and skilled surgery of Robert Jones. He expressed displeasure by gravely deformed and seriously crippled children unruffled and restrained feeling, which was felt for whom the best operative treatment was a rel- rather than heard.

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The optic nerve swelling should be assessed not only for the elevation antimicrobial cutting boards buy trimethoprim uk, but also the presence of nerve fiber layer infarcts antibiotics for uti keflex 480 mg trimethoprim buy fast delivery, hemorrhages antibiotics starting with c discount 480 mg trimethoprim with visa, exudates, and macular edema. The latter findings are evidence of chronicity and a greater likelihood of permanent damage to the visual pathways. Papilledema is occasionally seen in infants with PPTC, even among those who have open fontanelles. Visual acuity is typically normal, though about 1=3 of the children able to com- plete optotype acuity testing will present with reduced acuity in their better eye. Decreased vision should be considered a sign both of chronicity and of high pressure and often signals irreparable visual loss. This may be from paresis of one or both lateral rectus muscles from abducens nerve damage, but may also occur without clinical evidence of an ocular motor neuropa- thy. Other ocular motor findings include trochlear nerve paresis, oculomotor nerve paresis, internuclear ophthalmo- plegia, and hypertropias, all of which produce diplopia or torticollis in an attempt to fuse a vertical misalignment. Neurological signs, other than the ocular motor abnormalities, are unusual, except for a facial nerve palsy, which has been reported in a number of series. Etiologies (Table 1) Cerebral venous drainage impairment is the most often cited association with PPTC. Venous sinus thrombosis is a common cause, usually of the lateral sinus, frequently with a history of otitis media. Thromboses of the superior sagittal sinus or cavernous sinus have also been implicated. Sinus thrombosis may also be the final pathway for some of the other associations. The use of some antibiotics may cause a nondose related rise in intracranial pressure. In my experience, this is most commonly seen with doxycycline and minocycline, two tetracycline class antibiotics used for the management of acne. EVALUATION A history is performed specifically evaluating the patient for symptoms as well as any potential precipitating associations. The laboratory evaluation includes neuroima- ging of the brain and orbits looking for evidence of a mass lesion or hydrocephalus. For the diagnosis of PPTC, the scan should be normal with either small or normal ventricles. Lumbar Pseudotumor Cerebri 239 Table 1 Etiologies of Pediatric Pseudotumor Cerebri Cerebral venous drainage impairment Transverse sinus obstruction Sagittal sinus obstruction Coagulopathy Trauma Drugs Corticosteroid use or withdrawal Tetracycline type drugs (including minocycline and doxycycline) Cyclosorin Medroxy-progesterone Nalidixic acid Vitamin A Endocrinological conditions Hypoparathyroidism Menarche Thyroid replacement Nutritional Weight loss or gain Vitamin D deficiency Vitamin A deficiency Metabolic Renal disease Infectious Lyme puncture is necessary to examine the composition of the spinal fluid, which must have normal cell count, cytology, and chemistry. The opening pressure should be measured with a manometer prior to removing any spinal fluid. The patient needs to be calm and in a recumbent position, occasionally requiring sedation. Intracranial pressures greater than 200 mm of water support the diagnosis. A neurological exam should be performed, but is most often unremarkable (Fig. A complete ophthalmological evaluation should be performed as soon as pos- sible. This examination should include careful measurement of best-corrected visual acuity using age appropriate test charts, color vision, pupillary light responses, visual fields, and ophthalmoscopy. Color photographs of the optic discs should also be obtained for comparison at subsequent visits. Quantitative perimetry is preferred because it seems to be the most sensitive test of optic nerve dysfunction. In addition, such studies can be electronically compared from one visit to the next, improving the clinicians ability to detect improvement or deterioration. Recently, computerized scanning using light or ultrasound has become widely available. Such electronic images can be compared both visually and electronically from visit to visit enhancing the physician’s ability to detect improvement or progression of the disc swelling. Ophthalmoscopy should include an evaluation of the optic disc for swelling, hemorrhage, exudates, as well as the pre- sence or absence of venous pulsations. Normal pulsations are usually compatible with normal intracranial pressure, though the absence of pulsations occurs in both normal and high intracranial pressure states. If there is evidence of an optic neuro- pathy on any of the tests of acuity, color vision, pupils or field, the pace of treatment 240 Repka Figure 1 Treatment algorithm.

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Normally antibiotics weight loss generic trimethoprim 480 mg free shipping, the anti-oncogen proteins are responsive to cell growth antibiotic justification form purchase trimethoprim 960 mg free shipping, and so act as a signal to the cell to halt growth antibiotics for sinus infection bronchitis purchase trimethoprim 480 mg otc. By disrupting the anti- AAdjuvant DJUVANT oncogene proteins, this stop signal is eliminated, resulting in the continued and uncontrolled growth of the cell. A tumor is An adjuvant is any substance that enhances the response of the produced. Thus, adenoviruses have become important as one immune system to the foreign material termed an antigen. An Such cancers may be a by-product of adenovirus infec- adjuvant can also be any substance that enhances the effect of tions. The When antigen is injected into an organism being used to infections are fairly common. For example, most children will raise antibodies the effect is to stimulate a greater and more have antibodies to at least four types of adenovirus. The stick-and-ball appearing penton fibers may have useful if a substance itself is not strongly recognized by the a role in the attachment of the virus particle to a protein on the immune system. An example of such a weak immunogen is surface of the host epithelial cell. Adenovirus infections have contributed to the spread of Adjuvants exert their effect in several different ways. The flu-like symptoms of some adenovirus infec- antigen to the immune system over a prolonged period of time. The immune response does not occur all at once, but rather is 4 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Agar and agarose continuous over a longer time. This inter- aerobic bacteria and other organisms, a compound called action may stimulate the immune cells to heightened activity. The pyruvic acid in turn is broken down via a series ingestion of the antigen by the immune cell known as the of reactions that collectively are called the tricarboxylic acid phagocyte. This enhanced phagocytosis presents more anti- cycle, or the Kreb’s cycle (named after one the cycle’s discov- gens to the other cells that form the antibody. A principle product of the Kreb’s cycle There are several different types of antigens. The adju- is a compound called nicotinamide adenine dinucleotide vant selected typically depends on the animal being used to gen- (NADH2). Different adjuvants produce different reactions of which oxygen is a key. Some adjuvants are inappropri- The energy-generating process in which oxygen func- ate for certain animals, due to the inflammation, tissue damage, tions is termed aerobic respiration. Anaerobic respiration exists, and ence the choice of an adjuvant include the injection site, the involves the use of an electron acceptor other than oxygen. This type of adjuvant down (this is also known as oxidation) to carbon dioxide and enhances the response to the immunogen of choice via the water. The complete breakdown process yields 38 molecules inclusion of a type of bacteria called mycobacteria into a mix- of adenine triphosphate (ATP) for each molecule of the sugar ture of oil and water. The oil and water acts to emulsify, or spread evenly transport that does not involve oxygen also generates ATP, but throughout the suspension, the mycobacteria and the immuno- not in the same quantity as with aerobic respiration. The other so-called fermentative type of energy generation is a fall-back mechanism to permit the organism’s See also Immunity: active, passive, and delayed survival in an oxygen-depleted environment. The aerobic mode of energy production can occur in the disperse cytoplasm of bacteria and in the compartmental- AAerobes EROBES ized regions of yeast, fungi and algae cells. In the latter microorganisms, the structure in which the reactions take Aerobic microorganisms require the presence of oxygen for place is called the mitochondrion. Molecular oxygen functions in the respiratory path- chondrion are coordinated with other energy-requiring way of the microbes to produce the energy necessary for life. See also Carbon cycle in microorganisms; Metabolism The opposite of an aerobe is an anaerobe.

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Campbell had not planned on retiring from building maintenance two years previously infection after tooth extraction order trimethoprim in india. But my legs got so bad that I figured I’d take early retirement and get done with it antibiotic 2013 buy trimethoprim 480 mg with mastercard. The pain got so bad at the end that I could only walk 35 ear infection 9 year old 960 mg trimethoprim with mastercard, 40 yards, and then I’d stop and rest. Sitting in a straight- backed chair, I had to get halfway across the room before I could get straightened up and my legs working. Her father had it before her, and my brother just had his second knee replaced. For the last thirty years of her life, maybe forty, she rarely ever went out. One day, she weighed over 300 pounds, and she never really tried to do anything. But then the doctor said they couldn’t guarantee me more than fifteen years, and fifty-five is kind of young to get something like that done. Then when I couldn’t get around anymore, it just seemed like the practical thing to do. Campbell patted his right knee; that replacement had worked like a charm. He and Betty planned to return to long walks at the local shopping mall. I got a little bit in the left one, but that’s going to be here until the swelling goes down. The only thing I would advise other people is, when they start having troubles and their leg starts acting up, get it checked out. The left knee replacement had alleviated his pain and restored his ability to walk, but Mike had died a few weeks before my call from an unusually ag- gressive pneumonia. Landau sounded shaken that he could not save this man he had known for fifteen years. People describe weakness, over- Sensations of Walking / 31 whelming fatigue, imbalance, tripping or careening into objects, stubbing toes on tiny bumps and cracks, and having trouble initiating, maintaining, or controlling movement. They have difficulty describing their sensations to loved ones, friends, and physicians. Walter Masterson, in his late fifties, was a business executive flying frequently abroad for ex- hausting negotiations. He disregarded the initial symptoms of amyo- trophic lateral sclerosis (ALS), Lou Gehrig’s disease. I started being bothered by the limp in the summer but didn’t go to the doctor until that fall. I would go overseas for two, three, sometimes even four weeks at a time, which meant I was carrying damned near everything I own and running through airports with this massive bag banging against my knee. So I never really thought much about it except that this one didn’t go away. I came in for a variety of torture tests, which were essentially measuring the nerves’ response to being stabbed and jolted. Progres- sively, I had to have braces on one leg and then both legs to help me stand up. Shortly thereafter I got a wheelchair for outside and a tricycle walker for home. Increasing weakness in my legs that has taken me from limping to not being able to walk at all. Lester Goodall, in his mid fifties, had long-standing diabetes requiring insulin. A manager in a Fortune 500 company, Lester’s recreational passion was throwing darts in leagues organized at local pubs. I would pick up my darts and try to get into the right position holding the darts, but I couldn’t.

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In 1785 he moved to his last abode antibiotic vitamins purchase trimethoprim with visa, a large subordinated to the study of comparative anatomy house on the east side of Leicester Square antibiotics mechanism of action purchase cheap trimethoprim online. He and biology bacteriophage generic trimethoprim 480 mg line, which demanded all the time and bought another house close by and, on the land money that he could devote. He acquired speci- between, built a suite of rooms and a great mens from the menageries—dissecting the bodies museum. In his new quarters the dissection and of animals that died; and in order to study living collection of natural history specimens went on animals both by experiment and by observation apace. At the same time his practice grew to such of their habits, he bought, in 1764, 2 acres of land an extent that on the death of Percivall Pott in at Earl’s Court, which at that time was in the 1788, Hunter succeeded him as the first surgeon country, 2 miles beyond London. In his attention to patients he was ized an experimental station and housed a great thoughtful and self-sacrificing; he gave his serv- variety of wild and domestic animals from all ices free to non-beneficed clergy and struggling over the world. Dissected speci- and always aimed at diminishing their severity, mens were preserved carefully, and thus was built regarding many of them as an imperfection of the up an anatomical and pathological museum, art of healing. He was deeply impressed by the which became the bedrock of scientific study of natural resistance of the body to disease, and by surgery in England. He was elected a Fellow of its struggle against anything impairing the func- the Royal Society in 1767 and was awarded its tion of one of its parts. In the next year he was elected surgeon was that of a helper, claiming no more surgeon to St. George’s Hospital and soon after- for his operation than lending his aid in that resist- wards became a member of the Corporation of ance and that struggle. The pupils he attracted, who afterwards inherent power of living tissues that led to his achieved great distinction, included Edward classical operation for popliteal aneurism. He was Jenner, Abernethy, Cline, Earle, and Astley alarmed at the high mortality of prevailing treat- Cooper. Unlike other teachers, his lectures on ment by amputation, or double ligature with evac- surgery were based upon rational pathology; he uation of the blood sac. He had tied one of the insisted that the principles of surgery must first be external carotid arteries of a stag in order to understood before the cause of disease could be observe the effect upon growth of the correspon- appreciated. But he had none of the eloquence of ding antler; to his surprise the horny outgrowth his brother; extempore expression of the thoughts still kept growing. He to his ligature, he had the animal killed for inspec- read almost entirely from manuscript and even tion and to his amazement Hunter found that then his language was labored. But it was what small branches of the artery above and below the John Hunter had to say that was important rather occlusion had enlarged under “the stimulus of than his manner of saying it. The casket was necessity,” and by their anastomoses had restored unadorned but the treasure within was of great blood supply to the growing part. George’s circulation after ligation of the main artery, the Hospital, he moved to a house in Jermyn Street, same should happen in the human lower limb previously occupied by his brother, which was after occlusion of the femoral artery by single lig- nearer to hospital, better situated for private con- ature. Acting upon this deduction, in 1785, he tied sulting work, and offered greater accommodation the femoral artery in the lower part of the thigh 153 Who’s Who in Orthopedics in a patient at St. George’s Hospital with a thicker by the deposition of new matter sub- popliteal aneurism. Within 6 weeks the man left periosteally; and that bone is constantly under- hospital with his life and his limb. The fibromus- going change with simultaneous absorption and cular sheath through which the femoral artery deposition of osseous tissue—an observation passes has ever since been known as Hunter’s confirmed later by the microscope. The evolution of this operation illustrates Study of the structure and function of the John Hunter’s scientific approach and appeal to human body was only part of Hunter’s work. His experimental methods in seeking the solution of labors covered the whole field of natural history. He sought to An investigation of great interest to orthopedic unfold the various phases of life. In dissected over 500 different species of animals 1767, while dancing, he ruptured his tendo and numerous varieties of plants. Thereupon he studied in animals the ranged from the spermaceti whale, with its aorta manner of reunion of divided tendons. His study of the distance from it, and killed the dogs at different structure and of the social habits of this honey- periods to see the progress of the union, which making insect was so extensive and protracted was found to be similar to that of fractured bones that it was only close to the end of his life that he where the skin is not wounded. The ends of the divided tendons had been his only contribution to knowledge, his retracted but “the uniting medium was not distin- name would have been memorable.

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Cross References Trömner’s sign; Upper motor neurone (UMN) Syndrome - 154 - Holmes’s Tremor H Hoffmann-Tinel Sign - see TINEL’S SIGN Holmes-Adie Pupil bacteria 4 conditions generic 960 mg trimethoprim with mastercard, Holmes-Adie Syndrome The Holmes-Adie antibiotics dogs can take discount trimethoprim line, or tonic medicine for uti boots buy generic trimethoprim 480 mg online, pupil is an enlarged pupil which, in a dark- ened environment, is unresponsive to a phasic light stimulus, but may respond slowly to a tonic light stimulus. Reaction to accommodation is preserved (partial iridoplegia), hence this is one of the causes of light-near pupillary dissociation (q. A Holmes-Adie pupil is usually unilateral, and hence a cause of anisocoria. Holmes-Adie pupil may be associated with other neurological fea- tures (Holmes-Adie syndrome). These include loss of lower limb ten- don reflexes (especially ankle jerks); impaired corneal sensation; chronic cough; and localized or generalized anhidrosis, sometimes with hyperhidrosis (Ross’s syndrome). Pathophysiologically Holmes-Adie pupil results from a peripheral lesion of the parasympathetic autonomic nervous system and shows denervation supersensitivity, constricting with application of dilute (0. Philadelphia: Lippincott Williams & Wilkins, 2002: 135-146 Martinelli P. London: Imperial College Press, 2003: 249-251 Cross References Anhidrosis; Anisocoria; Hyperhidrosis; Light-near pupillary dissocia- tion; Pseudo-argyll robertson pupil Holmes’s Tremor Holmes’s tremor, also known as rubral tremor, or midbrain tremor, has been defined as a rest and intention tremor, of frequency < 4. The rest tremor may resemble parkinsonian tremor, and is exacerbated by sus- tained postures and voluntary movements. Hence there are features of rest, postural and kinetic (intention) tremor. Once attributed to lesions of the red nucleus (hence “rubral”), the anatomical substrate is now thought to be interruption of fibers of the superior cerebellar peduncle (hence “midbrain”) carrying cerebellothalamic and/or cerebello-olivary projec- tions; lesions of the ipsilateral cerebellar dentate nucleus may produce a similar clinical picture. If a causative lesion is defined, there is typically a delay before tremor appearance (4 weeks to 2 years). Brain 2001; 124: 720-730 - 155 - H Hoover’s Sign Deuschl G, Bain P, Brin M and an Ad Hoc Scientific Committee. Movement Disorders 1998; 13(suppl3): 2-23 Cross References Tremor Hoover’s Sign Hoover’s sign may be used to help differentiate organic from functional hemiplegia or monoplegia. It is based on the fact that when a recum- bent patient attempts to lift one leg, downward pressure is felt under the heel of the other leg, hip extension being a normal synergistic or synkinetic movement. The finding of this synkinetic movement, detected when the heel of the supposedly paralyzed leg presses down on the examiner’s palm, constitutes Hoover’s sign: no increase in pressure is felt beneath the heel of a paralyzed leg in an organic hemiplegia. In addition, the synkinetic hip extension movement is accentuated when attempting to raise a contralateral paretic leg, whereas in functional weakness it is abolished. Practical Neurology 2001; 1: 50-53 Cross References “Arm drop”; Babinski’s trunk-thigh test; Functional weakness and sensory disturbance; Synkinesia, Synkinesis Horner’s Syndrome Horner’s syndrome is defined by a constellation of clinical findings, most usually occurring unilaterally, viz. The first two mentioned signs are usually the most evident and bring the patient to medical attention; the latter two are usually less evident or absent. Additional features which may be seen include: ● Heterochromia iridis, different color of the iris (if the lesion is con- genital) ● Elevation of the inferior eyelid due to a weak inferior tarsal mus- cle (“reverse ptosis,” or “upside-down ptosis”). Horner’s syndrome results from impairment of ocular sympa- thetic innervation. The sympathetic innervation of the eye consists of a long, three neurone, pathway, extending from the diencephalon down - 156 - Hyperacusis H to the cervicothoracic spinal cord, then back up to the eye via the supe- rior cervical ganglion and the internal carotid artery, and the oph- thalmic division of the trigeminal (V) nerve. A wide variety of pathological processes, spread across a large area, may cause a Horner’s syndrome, although many examples remain idiopathic despite intensive investigation. Recognized causes include: Brainstem/cervical cord disease (vascular, demyelination, syringomyelia) Pancoast tumor Malignant cervical lymph nodes Carotid aneurysm, carotid artery dissection Involvement of T1 fibers, e. London: Imperial College Press, 2003: 252-255 Cross References Anhidrosis; Anisocoria; Enophthalmos; Miosis; Plexopathy; Ptosis; Radiculopathy Hoyt-Spencer Sign This name is given to the triad of findings characteristic of chronic optic nerve compression, especially due to spheno-orbital optic nerve sheath meningiomas: Optociliary shunt vessels Disc pallor Visual loss “Hung-Up” Reflexes - see WOLTMAN’S SIGN Hutchinson’s Pupil Hutchinson’s pupil is unilateral pupillary dilatation ipsilateral to a supratentorial (usually extrinsic) space-occupying lesion, which may be the earliest sign of raised intracranial pressure. It reflects involve- ment of peripheral pupilloconstrictor fibers in the oculomotor (III) nerve, perhaps due to compression on the margin of the tentorium. Cross References Anisocoria; Mydriasis; Oculomotor (III) nerve palsy Hyperacusis Hyperacusis is an abnormal loudness of sounds, especially low tones, due to paralysis of the stapedius muscle, whose normal reflex function is to damp conduction across the ossicular chain of the middle ear. This most commonly occurs with lower motor neurone facial (VII) nerve (Bell’s) palsy, located proximal to the nerve to stapedius. Ageusia - 157 - H Hyperalgesia may also be present if the chorda tympani branch of the facial nerve is involved. Reduction or absence of the stapedius reflex may be tested using the stethoscope loudness imbalance test: with a stethoscope placed in the patients ears, a vibrating tuning fork is placed on the bell.

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It is clear that at 15 years infection vs colonization purchase trimethoprim pills in toronto, 59% for VFO alone antibiotics for acne cause yeast infection order 960 mg trimethoprim visa, and 58% for VO plus Chiari’s pelvic osteotomy virus hunters of the cdc purchase trimethoprim with a mastercard, are seen, the latter group being somewhat inferior (Fig. VO, valgus osteotomy Complications of VFO The complications of the operation included 4 cases of intraoperative fracture; 2 were a highly comminuted head fracture and they were excluded from the analysis. There were 3 cases of transient sciatic nerve paresis in Chiari combination. Seven cases had superficial infection and 3 cases delayed healing and non-union. The latter cases were successfully treated by addi- tional procedures such as implant exchange with bone graft. Contributing Factors on Clinical and Radiologic Results As for the factors contributing to clinical results, Maistrelli et al. Our series showed that the results are very poor when the range of motion of the joint was less than 40°. Cysts disappeared in about 3 months to 1 year; osteosclerosis began to disappear somewhat later than the disappearance of cysts; for the growth of roof osteophyte, only 1 of 6 cases without an initial presence of roof osteophytes showed new growth. If roof osteophytes were present at the beginning, and if the initial size was about 6–10mm, good growth and maturation were observed in more than half the cases. In cases where roof osteo- phytes are absent, we cannot expect new growth. He said that preoperative AHI must be 60% for OA Joint Reconstruction Without Replacement Surgery 173 Table 1. Contributing factors to radiologic results of valgus-flexion osteotomy (VFO) Good Fair Poor 19 (63. AHI, acetabular head index; RO, roof osteophyte Data are mean ± SD Source: From Uchiyama et al. However, successful cases had preoperative AHI of 70%–73%; AHI immediately postoperative was 73%, the length of the roof osteophyte was 8. Other factors, such as age, body mass index (BMI), Sharp’s angle, or the size of the capital drop, were not directly associated with the results (Table 1). Discussion of the Biological and Biomechanical Mechanism of VFO Now I turn to a discussion of the biological and biomechanical mechanism of VFO. The basic idea is that biological effects can be introduced with the improvement of the biomechanical environment in the diseased hip joints. To ascertain the biological effect, we performed histological evaluation of 15 joints with good postoperative remodeling of the articular surface. At the time of implant removal, 1 to 3 years after osteotomy, histological specimens were taken from the patients with their consent. Under arthroscopic control, biopsy specimens were harvested, through the blade channel, from the area where there was no joint cartilage before the index surgery [15,16]. The arthrogram showed some radiolucent lines, above and below the contrast medium, which area was harvested (Fig. The tissue is very well stained by Safranin-O; the superficial layer has formed a relatively smooth articu- lar surface. Unlike normal cartilage, however, the feature is that the fibrous structure is relatively coarse. Looking at the superficial layer, there are spindle-shaped cells within the fibrous structure that run in parallel to the articular surface (Fig. The middle layer has relatively round cells with bright cytoplasm, conceivably cartilagi- nous cells, within the meshlike network of the fibrous structure (Fig. In the deep layer, within the fibrous structure, which runs completely perpendicular to the weight- bearing surface and stains strongly with Safranin O, bright round cartilaginous cells are observed. Another point to note is that the deepest part of the reparative tissue maintains communication with the bone marrow, and no tidemarks or subchondral bone plate are found (Fig. If S-100 protein is used to stain the tissue, most cells stain positive, substantiating the finding that they are indeed chondrocytes (Fig. Histological findings of surface repair tissue harvested from the femoral head of the patient presented on Fig.

Mannig, 35 years: Assomeofthe comments made in this group may be of a personal or private nature, other participants should respect the confidentiality of individuals and also not disclose infor- mation directly to third parties.

Ugolf, 55 years: While the ECG is an invaluable tool for the observation of heart rate and rhythm, as well as for the diagnosis of conduction abnormalities, ischaemia, and infarcts, its detailed interpretation is not without pitfalls.

Goose, 60 years: As with Chaddock’s sign and Oppenheim’s sign, this reflects an expansion of the receptive field of the reflex.

Anog, 27 years: This is actually a good way to improve your surgical understanding as long as you take the correct approach.

Lars, 26 years: She went to the health food store to find a coffee substitute and purchased a tea that was supposed to be good for the stomach.

Kerth, 53 years: The pain can radiate to behind the eyes and is often described as a feeling of pressure.

Milten, 22 years: For mobility-related services, questions about scientific evidence show- ing the effectiveness of interventions loom large.

Yussuf, 59 years: Is the child taking drugs that may influence feeding or swallowing function?

Candela, 44 years: Such policies were favoured by the absolutist dictatorships on the European continent, but were regarded as anathema to capitalist principles of individual freedom (especially in matters of trade).

Fabio, 36 years: Brown to the After his retirement to Rhode Island, he con- Palace and thanked them for their care of the tinued his interest in teaching as a consultant at British seamen.

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