By A. Seruk. Boston College. 2018.
Arachnoiditis secondary to either meningitis or subarachnoid hemorrhage can also occlude the basal foramina and cause obstructive hydrocepha- lus buy kamagra effervescent 100 mg low price. In addition discount kamagra effervescent 100mg amex, infants with Chiari II malformations and myelomeningoceles have hydrocephalus secondary to blockage of CSF ﬂow from basilar obstruction. Arachnoid Granulations Sclerosis or scarring of the arachnoid granulations can occur after meningitis, sub- arachnoid hemorrhage, or trauma. The subarachnoid spaces over the convexities enlarge, thus forming a condition often referred to as ‘‘external hydrocephalus. Symptomatic external hydrocephalus is treated with a subdural= subarachnoid to peritoneal shunt. CLINICAL FEATURES Premature Infants Hydrocephalus in premature infants is predominantly caused by posthemorrhagic hydrocephalus (PHH). Because the poorly myelinated premature brain is so easily compressed and the skull is so distensible, premature infants can develop consider- able ventriculomegaly before their head circumference increases. Infants with PHH may have no symptoms or may exhibit increasing spells of apnea and bradycardia. Poor feeding and vomiting are uncommon signs of hydrocephalus in premature infants. If ventriculomegaly progresses and ICP increases, the anterior fontanelle becomes convex, tense, and nonpulsatile; and the cranial sutures splay and the scalp veins distend. As ventriculomegaly persists, the head develops a globoid shape, and the head circumference increases at a rapid rate. Table 2 Signs and Symptoms of Hydrocephalus in Children Premature infants Infants Toddlers and older Apnea Irritability Headache Bradycardia Vomiting Vomiting Tense fontanelle Drowsiness Lethargy Distended scalp veins Macrocephaly Diplopia Globoid head shape Distended scalp veins Papilledema Rapid head growth Frontal bossing Lateral rectus palsy Macewen’s sign Hyper-reﬂexia-clonus Poor head control Lateral rectus palsy ‘‘Setting-sun’’ sign (From Elsevier from: P. Signs include macrocephaly, a convex and full anterior fontanelle, distended scalp veins, cranial suture splaying, frontal bossing, ‘‘cracked pot’’ sound on skull percussion over dilated ventricles (Macewen’s sign), poor head control, lat- eral rectus palsies, and the ‘‘setting-sun’’ sign, in which the eyes are inferiorly deviated. Paralysis of upgaze and Parinaud’s sign herald dilation of the suprapineal recess (Table 2). Head cir- cumference increases by 2 cm=month during the ﬁrst 3 months, by 1 cm=month from 4 to 6 months, and by 0. Head circumference increases that are progressive and rapid, crossing percentile curves on the head growth chart are a stronger diagnostic indicator of hydrocephalus than increases that are consistently above, but parallel to the 95% percentile curve. Older Children Hydrocephalus after infancy is usually secondary to trauma or neoplasms. The pre- dominant symptom is usually a dull and steady headache, which typically occurs upon awakening. It may be associated with lethargy, and often improves after vomit- ing. The headaches slowly increase in frequency and severity over days or weeks. Children presenting with headaches, vomiting, and drowsiness are unfortu- nately often misdiagnosed as having early meningitis; thus, a head computerized tomography (CT) or MR imaging should be performed to rule out hydrocephalus, hematoma, or tumor before a lumbar puncture is attempted. Older children often present with decreased school performance and behavioral disturbances, as well as endocrinopathies (e. Common signs include papilledema and lateral rectus palsies (unilateral or bilateral). Rarely, children with hydrocepha- lus may experience transient or permanent blindness if the posterior cerebral arteries are compressed against the tentorium. If the hydrocephalus is severe, Cushing’s triad of bradycardia, systemic hypertension, and irregular breathing patterns, as well as autonomic dysfunction, may occur. Cushing’s triad is rare and often denotes very high ICP requiring emer- gency treatment (Table 2). DIAGNOSIS Historically, several imaging studies were commonly used before the advent of CT scans in 1976. Skull radiographs demonstrate several diagnostic signs, including cra- nial suture separation in infants, as well as a ‘‘beaten copper’’ appearance and enlarged sella in older children. Skull radiographs have since been supplanted by more modern imaging studies such as cranial ultrasonography, CT scanning, and 30 Avellino MR imaging that demonstrate increased ventricular size, the site of pathological obstruction, and may show transependymal resorption. TREATMENT The treatment of hydrocephalus can be divided into nonsurgical approaches and surgical approaches, which in turn can be divided into nonshunting or shunting procedures. The goals of any successful management of hydrocephalus are: (1) optimal neurological outcome and (2) preservation of cosmesis. The radiographic ﬁnding of normal-sized ventricles should not be considered the goal of any therapeutic modality. Nonsurgical Options There is no nonsurgical medical treatment that deﬁnitively treats hydrocephalus effectively. Even if CSF production were to be reduced by 33%, ICP would only modestly decrease by 1. Historically, acetazolamide and furose- mide have been used to treat hydrocephalus. Although both agents can decrease CSF production for a few days, they do not signiﬁcantly reduce ventriculomegaly. Acetazolamide, a carbonic anhydrase inhibitor, is needed in large doses (25 mg=kg=day divided into three daily oral doses), and potential side effects include lethargy, poor feeding, tachypnea, diarrhea, nephrocalcinosis, and electrolyte imbal- ances (e. While acetazolamide has been used historically to treat premature infants with PHH, recent studies have shown it to be ineffective in avoidance of ven- tricular shunt placement and to be associated with increased neurological morbidity. Surgical—Nonshunting Options Whenever possible, the obstructing lesion that causes the hydrocephalus should be surgically removed.
This spirit was expressed in the emergence of self-help and pressure groups and in a general decline in deference to medical authority kamagra effervescent 100 mg without a prescription. Two movements—feminism and ‘anti-psychiatry’—were particularly influential in the growing challenge to the medical profession order 100mg kamagra effervescent overnight delivery. Though these movements expressed an individualistic and consumerist perspective, both were associated with wider goals of personal and social liberation. These movements expressed the concerns of patients, but they also won some support among a younger generation of radical practitioners. They were also significant in linking the discontents of the world of medicine with those of the wider society. The women’s health movement criticised medical intervention in women’s lives as paternalistic and patronising and particularly questioned doctors’ control over pregnancy and childbirth, contraception and abortion. British feminist Ann Oakley provided a list of controversies over ‘the modern male-controlled reproductive care system’: These protests cover such topics as the undue use of surgical abortion techniques (as opposed to the safer and less traumatic suction method), the overuse of radical as opposed to conservative surgery for breast and reproductive tract diseases, the resistance of doctors to hormone replacement therapy for menopausal problems, inadequate attention paid to the psychological traumata of reproductive experiences, and, perhaps most central of all, the modern, male-controlled, hospitalized and increasingly technological pattern of child-birth management. She 136 THE CRISIS OF MODERN MEDICINE concluded by asserting that the political programme of the women’s movement should include regaining control over reproductive care from doctors who had taken it out of the hands of midwives and other ‘wise women’. The Boston Women’s Health Collective handbook Our Bodies Ourselves, first circulated in a duplicated form in 1971 and published in 1972, rapidly made an international impact (Boston Women’s Health Collective 1972). A Women’s Health Handbook, subtitled ‘a self-help guide’, inspired by the Boston group, was published in Britain (MacKeith 1976). These guides included detailed advice on ‘self-examination’ (including the use of a vaginal speculum) and information about a wide range of women’s health problems. The anti-psychiatry movement drew support from a number of intellectual currents that emerged in the 1960s. Erving Goffman’s Asylums, subtitled ‘essays on the social situation of mental patients and other inmates’, first published in 1961, was a powerful indictment of the dehumanising effect of the psychiatric hospital, based on his own anthropological fieldwork (Goffman 1961). Thomas Szasz, an American psychiatrist, with a right-wing libertarian outlook, wrote a number of provocatively titled books— such as The Myth of Mental Illness and the The Manufacture of Madness—in an increasingly outspoken challenge to the psychiatric mainstream (Szasz 1961, 1970). From a radical existentialist perspective the charismatic Scottish psychiatrist R. Laing argued in a number of works, starting from The Divided Self in 1960, that mental illness was more a socially-prescribed label than an objectively verifiable disease and that psychosis could be a process of healing that should not be suppressed by drugs (Laing 1960). In France, the philosopher Michel Foucault, best known for his historical studies of the role of psychiatric institutions in the social control processes of bourgeois society, also became associated with the anti-psychiatry movement (Foucault 1961). In the course of the 1970s, the ideas of anti-psychiatry were taken up by movements both of and on behalf of people with a range of psychiatric problems. They also became an influential current in the wider radical counterculture (for a brilliant critique of these trends see Peter Sedgwick’s Psychopolitics, 1982). In 1971 Ken Loach’s Family Life presented Laing’s theories on the causation of schizophrenia by dysfunctional family relationships. In 1975 Ken 137 THE CRISIS OF MODERN MEDICINE Kesey’s novel One Flew Over the Cuckoo’s Nest, which depicted psychiatric illness as a higher form of awareness and exposed the oppressive conditions of the mental hospital, was made into an award-winning film starring Jack Nicholson. One common feature of the questioning of established medicine from different social movements was a challenge to the authority of the medical profession. The tendency for the demand for rights in the USA to lead to legal intervention in relations between patients and doctors had the effect of undermining professional sovereignty. Trust in medical authority was displaced by a conception of the doctor- patient relationship as a partnership in decision-making. Yet even in Britain, where litigation was a marginal influence, there was a shift in the perception from that of the doctor as an essentially benign figure, to one from whom the patient needed a degree of protection. Feminists were scathing: ‘professionalism in medicine is nothing more than the institutionalisation of a male upper class monopoly’ (Ehrenreich and English, 1974:40). Left-wing commentators, particularly in America, exposed the ‘medical-industrial complex’, depicted the medical profession as an instrument of capitalist class rule and denounced ‘medical ideology’ (Navarro 1976; Waitzkin 1978). Commentators on medicine from other academic fields, formerly sympathetic towards doctors, increasingly ‘portrayed the medical profession as a dominating, monopolising, self-interested force’ (Starr, 1982:392). The radical critics of medicine were often fiercely polemical, but like the wider movements of which they were a part, they were optimistic about their capacity to change things and not lacking in alternative programmes. Undoubtedly some of medicine’s critics aspired to overthrow capitalism and patriarchy as well as the power of the medical profession, but many had more specific proposals for reform. Indeed some of these—such as demands for de- institutionalisation of treatment and care for the mentally ill and for the de-medicalisation of many aspects of childbirth—were rapidly assimilated by the mainstream. Pressures for reform of the American health-care system made some headway before becoming stalled in the complexities of the political process and its relations with doctors, insurers and other commercial interests. Parallel pressures for reform of the medical profession itself—notably in the recruitment of women—made steady progress. The proportion of women admitted to medical schools in Britain increased from 22 per cent in 1965–66, to 41 per cent in 1980–81 and reached 52 per cent in 1992–93 (Allen 1994). In the recessionary climate of the mid-1970s the radical upsurge was gradually contained and a conservative backlash gathered momentum. By the end of the decade the new right was in the ascendant with Margaret Thatcher in 10 Downing Street and her ideological ally Ronald Reagan in the White House. The new conservatism did not however mean that doctors would be delivered from their carping critics and freed to return to business as usual. The end of the era of consensus led to a growing scepticism about the scope for ameliorative intervention in society, whether by the state or by professionals, whether in the spheres of education, social services or health.
The meniscus tugging on the pain-sensitive synovium at its peripheral attachments produces the pain generic kamagra effervescent 100 mg visa. The test is notoriously inaccurate discount 100 mg kamagra effervescent visa, and in most situ- ations the pain with full ﬂexion and rotation is sufﬁcient to conﬁrm an injury to the meniscus. The mechanism of the popping with the McMurray test is demon- strated in the video on the CD. It shows the tibial plateau subluxing forward and trapping the posterior horn of the meniscus between the femur and the tibia. It also illustrates why the unstable knee has a high incidence of meniscal tears. Collateral Ligament Assessment The collateral ligaments are assessed by varus and valgus stress testing at 0° and 30° (Fig. Valgus stress is applied to the knee to test the medial collateral ligament. Grade 2 has laxity with an end- point, and grade 3 is gross laxity at both 0° and 30°. The site of tender- ness on the ligament can determine the site of injury (i. The examination of the collaterals is important to determine whether the ACL injury is isolated. Anterior Drawer Test This test is generally not useful for detecting injury in the acute situa- tion (Fig. Do not confuse the anterior motion with the knee that is posteriorly subluxed and the anterior motion of pulling the knee to the neutral position. In the anterior drawer test, the ACL is stressed by pulling the tibia anteriorly at 90° of ﬂexion. When the quadri- ceps is contracted against resistance with the knee ﬂexed at 30° and without weight bearing, there is an anterior displacement of the tibia (this is an open kinetic chain exercise). Open kinetic chain exercise is also seen with the patient on the quadriceps machine in a ﬁtness room. The quadriceps pulls the tibia forward if there is no ACL or causes signiﬁcant strain on the ACL graft. In the early rehabilitation phase, this exercise must be avoided to prevent strain on the recently implanted graft. Associated Ligament Injuries It is always important to perform a posterior drawer test (Fig. If this is done routinely, you will not miss a posterior cruciate ligament 22 2. The external rotation of the tibia must be measured at both 90° and 30° to rule out associated injury to the posterolateral corner. Imaging Plain Radiographs The screening examination should be a simple anteroposterior and lateral radiograph of the knee. This will reveal open growth plates,ACL bony avulsions, signiﬁcant osteochondral fractures, tibial plateau frac- tures, or epiphyseal fractures. Tomograms If the radiograph is negative, but considerable bony tenderness exists, then tomograms should be done to rule out plateau fractures. Computed Tomography Scan The 3-D scan can help plan treatment for associated tibial plateau fractures. Examination Under Anesthesia and Arthroscopy 23 Bone Scan If the pain persists, this scan may conﬁrm occult bony injury. Magnetic Resonance Imaging In a few situations, magnetic resonance imaging (MRI) will change your management of an injury. If the loss of extension persists, the MRI can be performed to determine whether this is a bucket-handle tear or an impingement of the ACL bundle, a cyclops lesion. The meniscus tear should be repaired early and, in some situations, the ACL reconstruction should be delayed until a good range of motion has been achieved after the meniscus repair. In the cyclops lesion, both the debridement of the ligament ends and the ACL reconstruction can be done simultaneously as described by Pinczewski. Remember that a good physical examination by an expe- rienced physician is more reliable than an MRI. Examination Under Anesthesia and Arthroscopy The arthroscope has been the key to unlocking the diagnosis of knee pathology (Fig. The arthroscope has improved the diagnosis of knee injuries, but the scope examination is only one aspect of the puzzle. One of the mistakes residents make is to go ahead with the arthroscopy before performing a clinical examination of the knee. The examination under anesthesia (EUA) is a valuable adjunct to the diagnostic work- up. It is often difﬁcult to examine the very large knee of a football player with multi- ple ligament injuries in the training room. Arthroscopy of the acute knee presents no more technical prob- lems than with the elective case. The synovium and ligamentum mucosum around the ACL must frequently be removed to fully assess the degree of liga- ment injury. The video on the CD shows how the diagnostic arthroscopy must be performed in a similar fashion each time, so that the knee will be completely examined and no region forgotten. The “W” procedure enables the physician to view the patellofemoral joint, the medial gutter, the medial compart- ment with the medial meniscus, and then to go over the top of the 24 2. The capsular injury may be seen by inspecting the gutters, and examining over and under the meniscus. If there is signiﬁcant capsular tearing, then gravity pressure only, rather than a pump, should be used. The ACL tear has produced a stump at the front of the knee that prevents full extension.
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