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Hemorrhage episode of severe trauma are subdivided into muscle strain dissecting within the muscle stroma order atomoxetine 40 mg amex treatment 4 toilet infection, not forming a dis- and muscle contusion generic 40mg atomoxetine amex symptoms 3dpo, depending on the mechanism of in- crete collection buy cheap atomoxetine 25 mg 4 medications, is known as parenchymal hemorrhage. A muscle strain is caused by an indirect injury, When blood forms a discrete collection, the mass is re- whereas a contusion is due to direct concussive trauma ferred to as a hematoma. The muscle alter- and hematoma coexist in most cases with extensive ations of contusion are identical to those seen high-grade bleeding. Parenchymal hemorrhage does not have a brain muscle strains but the location of the injury is independent correlate so its appearance is less well-known to radiolo- of the myotendinous junction, corresponding instead with gists. Contusions are more likely to be asso- little mass effect and has a lacy, feathery appearance ciated with extensive hemorrhage within the muscle. Parenchymal hemorrhage is best seen on inversion re- covery or T2-weighted sequences, and is often normal ap- Muscle Strain pearing on T1-weighted images. The appearance of a sub- acute parenchymal bleed is very nonspecific as the blood Muscle strains typically involve the myotendinous junc- does not undergo a phase of methemoglobin formation, tion of the muscle. Acute blood has by methemoglobin low signal intensity on both T1- and T2-weighted images due to the presence of intracellular deoxyhemoglobin. Subacute hematomas have a distinctive appearance due to the formation of methemoglobin, particularly at the pe- riphery of the hematoma (Fig. Methemoglobin pro- duces T1 shortening, resulting in high signal intensity within the hematoma on T1-weighted images. Fluid-fluid levels within the hematoma are common, particularly in large hematomas. In chronic hematoma, some of the iron in the methemoglobin is converted to hemosiderin and fer- ritin, which deposit in the hemorrhage and adjacent tissues. These substances result in signal loss on both T1- and T2- weighted images, producing a low-signal halo around the hematoma. Myositis Ossificans Myositis ossificans is a circumscribed mass of calcified and ossified granulation tissue that forms as a response to trauma. On excision, the mass was found tis ossificans may show a fat signal centrally due to mar- to beimmature myositis ossificans row formation or there may be persistent granulation- type tissue within its central regions. Compartment syndrome is seen most commonly in the lower extremity, typically be- low the knee, in patients who have undergone injury. However, any location can be involved, including the thigh, forearm and paraspinal musculature. Mild unilateral swelling and a slight increase of muscle intensity on T2-weighted images is present (Fig. Compartment calcification may be present, particularly Compartment pressures were subsequently obtained and confirmed in the peroneal compartment. Calcific tion in which either compartment syndrome progresses to myonecrosis: keys to early recognition. Radiology 208:815-820 cle appearance in six patients and a review of the literature. Is there a history Current imaging techniques have markedly improved our of notable trauma or anticoagulants? Despite these improved mained stable over a long period of time, varied in size, or modalities, the ultimate goal of imaging remains unchanged: is it growing? A history of continued growth is always sus- detecting the suspected lesion and establishing a diagnosis or, picious for malignancy. Unlike bone tumors, however, a more frequently, formulating an appropriate differential di- slowly growing soft-tissue mass is not invariably indicative agnosis, and radiologic staging of a lesion. Variation in lesion size with time or ac- intended as a summary of the radiologic manifestations of tivity would be exceedingly unusual for a malignancy, and soft-tissue tumors, but will present a systematic approach to suggests a process such as a ganglion or hemangioma. Primary soft-tissue sarco- differentiating benign from malignant soft-tissue lesions. Multiple lipomas are seen in 5-15% of patients presenting with a soft- Incidence tissue mass [5-7]. Aggressive Soft-tissue sarcomas, unlike benign soft-tissue lesions, are fibromatosis is multifocal in 10-15% of patients, and a sec- relatively uncommon, and are estimated to represent about ond soft-tissue mass in a patient with a previously confirmed 1% of all malignant tumors [1, 2]. Hajdu [1] noted that, in desmoid tumor should be regarded as a second desmoid tu- the United States, the incidence is about the same as that of mor until proven otherwise [8-10]. Soft-tissue matosis have multiple lesions and, although the diagnosis is sarcomas are two to three times as common as primary ma- often known or suspected, this is not always the case. Benign soft-tissue tumors are far agnosis may be suggested on the basis of imaging findings more common, although it is difficult to estimate the annu- by the identification of multiple lesions in a major nerve dis- al incidence because many lipomas, hemangiomas, and oth- tribution. A dominant or enlarging lesion in a patient with er benign lesions are not biopsied. The annual clinical inci- neurofibromatosis is suspect for malignant transformation. Despite dramatic technological advances in the ability to Preliminary Evaluation image soft-tissue tumors, the radiologic evaluation of a sus- pected soft-tissue sarcoma must begin with the radiograph. The initial evaluation of a patient with a suspected soft-tis- While frequently unrewarding, it is impossible to predeter- sue sarcoma begins with a thorough clinical history and ra- mine those tumors in which radiographs are critical for di- diologic evaluation. Radiographs may be diagnostic of a palpable le- vide key information, which will allow a specific diagnosis sion caused by an underlying skeletal deformity (such as even when imaging is nonspecific. Is there a history of a exuberant callus related to prior trauma) or exostosis, which previous tumor or underlying malignancy? A so reveal soft-tissue calcifications, which can be suggestive, Soft-Tissue Tumors and Tumor-Like Masses: A Systematic Approach to Diagnosis 55 and at times very characteristic, of a specific diagnosis. Field-of-view is dictated by the size and location of the Radiographs are also the best initial method of assess- lesion. In general, a small field-of-view is preferred; how- ing coexistent osseous involvement, such as remodeling, ever, it must be large enough to evaluate the lesion and to periosteal reaction, or overt osseous invasion and destruc- allow appropriate staging. It is useful to place a marker lesion, its pattern of mineralization or its relationship to over the area of clinical concern in order to insure it is ap- the adjacent osseous structures. This becomes important in evaluation in which the osseous anatomy is complex, such as the of lesions such as subcutaneous lipoma or lipomatosis, in pelvis, shoulder, hands and feet, and paraspinal regions. When small superficial lesions are being evaluated, care should be taken to insure that the Magnetic Resonance Imaging marker or patient position does not compress the mass. Standard contrast agents enhance the signal intensity on T1-weight- spin-echo images are most useful in establishing a specific ed spin-echo images of many tumors. In some cases it can diagnosis, when possible, and is the most reproducible tech- enhance the demarcation between tumor and muscle and nique, and the one most often referenced in the tumor imag- tumor and edema, as well as provide information on tumor ing literature. It is the imaging technique with which radi- vascularity [16,17]; information that is usually well delin- ologists are most familiar for tumor evaluation [12].

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It is also responsible for some cases of stomatitis in infants and the cause of infection of the gastrointestinal tract and elsewhere in immunosuppressed people purchase 10 mg atomoxetine otc symptoms quitting tobacco. It may contribute to the clinical picture in the intertrigo seen in the body folds of the obese and in the napkin area in infancy order 25 mg atomoxetine medicine wheel images. Oral and vaginal moniliasis responds to preparations of nystatin and amiphenazole as well as to the imidazoles discount atomoxetine 18 mg without a prescription 94 medications that can cause glaucoma. Some, such as histoplasmosis, cryptococcosis and coccidioidomycosis, are widespread systemic infections, which only occasionally involve the skin. Actinomycosis, sporotrichosis and blastomycosis infect the skin and subcuta- neous tissues, causing chronically inflamed hyperplastic and sometimes eroded lesions. Sporotrichosis may produce a series of inflamed nodules along the line of lymphatic drainage. Deep fungus infections of this type produce a granulomatous type of inflammation, with many giant cells and histiocytes as well as polymorphs and lymphocytes. Madura foot is a deep fungus infection of the foot and is seen in various coun- tries of the African continent and India. The affected foot is swollen and infil- trated by inflammatory tissue, with many sinuses. The infection spreads throughout the foot, invades bone and is very destructive and disabling. Clinical features Red, sore areas, which may blister, appear on the exposed skin surface (see Fig. Yellowish gold crust surmounts the lesions that appear and spread within a few days. It is, however, not uncommon for the signs of the lesions to appear over an area of eczema. In tropical and subtropical areas, an impetigo-like disorder is spread by flies and biting arthopods. This disorder is more destructive than ordinary impetigo and produces deeper, oozing and crusted sores and is caused mostly by beta- haemolytic streptococci. There have been several outbreaks of acute glomerulonephritis following episodes of this infective disorder. Treatment Local treatment with an antibacterial wash to remove the crust and debris, as well as a topical antimicrobial compound such as betadine or mupirocin are needed in all cases and, unless the area is solitary and very small, a systemic antibiotic such as penicillin V (250 mg 6-hourly for 7 days) is also required. Erysipelas Erysipelas is a severe infective disorder of the skin caused by the beta-haemolytic Streptococcus. There is sudden onset of a well-marginated, painful and swollen erythematous area, usually on the face or lower limbs (Fig. The inflammation may be very intense and the area may become haemorrhagic and even blister. Treatment with antibiotics by mouth (penicillin V, 250 mg 6-hourly) should be rapidly effective. Cellulitis This is a diffuse, inflammatory disorder of the subcutis and skin caused by several different micro-organisms and is of variable severity. It is relatively common, particularly on the limbs, and often occurs on legs affected by venous ulceration or by lymphoedema. There is pain, tenderness, slight swelling and a variable degree of diffuse erythema. Broad-spectrum antibiotics are indicated, as the micro-organisms may be Gram negative in type (e. Cephradine and flucloxacillin (250 mg of each 6-hourly) are one suitable combination. They are much less common now than 30 or even 20 years ago, presumably because of improved levels of hygiene. Nonetheless, there are still families and individuals who are troubled by recurrent boils. In many instances, the patho- genic Staphylococcus colonizes the external nares, the perineum or other body sites and is difficult to dislodge. The lesions are localized, red, tender and painful swellings; carbuncles may be quite large, perhaps 3 or 4 cm in diameter, and rep- resent the infection of several follicles. Systemic antibiotics are required and, whenever possible, their use should be guided by the pattern of sensitivities found by culture. It is spread by farm animals and, because the micro-organism has a resistant spore form, can stay on infected land for years. Several types of skin tuberculosis were once commonly seen, but are now quite rare in developed countries. It often has a thickened psoriasiform appearance, but blanching with a glass microscope slide (diascopy) will reveal grey-green foci (‘apple jelly nodules’) due to the underlying granulomatous inflammation. Treatment is initially with ‘triple therapy’ of rifampicin, pyrazinamide and iso- niazid over a 2-month period, followed by a ‘continuation’ treatment phase with isoniazid and pyrazinamide. Tuberculosis verrucosa cutis (warty tuberculosis) This is seen on the backs of the hands, knees, elbows and buttocks whenever abra- sive contact with the earth and expectorated tubercle bacilli has been made. Thickened, warty plaques are present, which are sometimes misdiagnosed as viral warts. Diagnosis is confirmed by biopsy showing tuberculoid granulomata and caseation necrosis. Other forms of cutaneous tuberculosis ● A persistent ulcer may arise at the site of inoculation as a ‘primary’ infection. In papulo- necrotic tuberculide, papules arise and develop central necrosis with a black crust. Erythema induratum is an uncommon, odd disorder, which in many cases appears to fulfil the criterion of being a response to tuberculous infection. It is 46 Bacterial infection of the skin characterized by the development of plaque-like areas of induration and necrosis on the lower calves and occurs predominantly in young women. It has a 3-week incubation period and causes plaques, abscesses and erosions on the elbows and knees in particular.

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According to the theory 433 Acupuncture Therapy of Neurological Diseases: A Neurobiological View of Zang-fu organs buy atomoxetine 25mg mastercard symptoms viral infection, the lung and the large intestine buy discount atomoxetine 10mg online symptoms 7 days post iui, as well as the spleen and the stomach atomoxetine 25mg fast delivery medications an 627, are the exterior-interior organs for each other. Hence, the smokers usually exhibit the heat-evil symptoms of the lung and stomach, such as cough with yellow sticky sputum, pain in the chest, xeromycteria, constipation, anorexia, xerostomia, halitosis, etc. Furthermore, smokers generally have a red tongue with yellow coating, and rapid pulse. Therefore, the principle of acupuncture treatment for smoking cessation is to clear away the heat-evil of the lung and stomach (Fig. Smokers usually present the heat evil symptoms of the lung and stomach, such as cough with yellow sticky sputum, pain in the chest, xeromycteria, constipation, anorexia, xerostomia, halitosis, etc. Therefore, the principle of acupuncture treatment for smoking cessation is to clear away the heat evil of lung and stomach. Researchers also found that the psychological factor of acupuncture treatment was principally from the support of therapists, but not the smokers themselves. When combined with the psychological and behavioral therapies, the effect of acupuncture treatment is observed to be better (Cui and Jiang 1992). Sun (2000) randomly divided 60 patients into two groups: auriculo-acupoints group and auriculo-acupoints with psychological treatment group. The patients of the latter group were given a 434 16 Acupuncture for Smoking Cessation professional introduction, transference, teaching, and rising morale. The results showed that there was obvious differences between the two groups, and the withdrawal symptoms of the auriculo-acupoints group, when compared with the auriculo-acupoints with psychological treatment group, were less and statistically insignificant. In summary, as a nature therapy, acupuncture is considered to be effective for smoking cessation, as it is presumed to regulate the whole body. However, there are still many problems that need to be addressed in the future, such as high recurrence rate, unstable immediate effects, etc. When compared with the pharmacologic or psychological methods, acupuncture therapy is observed to be unique and effective. However, owing to limited mechanistic researches, its use and development in the clinic environment is still not widespread. As the study on the effects of acupuncture treatment for smoking cessation has been carried out since the past 30 years, more work on the clinical study or basic research is believed to provide greater insight and offer great help to patients who are attempting to quit smoking. American Journal of Medicine 75: 1033 1036 Cui M (1996) The research development of withdrawal symptoms by acupuncture (continuation one). British Journal of Addition 86: 57 59 Hajek P, West R, Foulds J (1999) Randomized comparative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler. Zhongguo Ming Jian Liao Fa (Chinese Civilian Therapy) 14: 58 60 (in Chinese) Karnath B (2002) Smoking cessation. Zhen Jiu Lin Chuang Za Zhi (Journal of Clinical Acupuncture & Moxibustion) 16: 32 (in Chinese) Zhang Q (1990) 108 cases smokers treated by auriculo acupuncture and body acupuncture. Zhongguo Zhen Jiu (Chinese Acupuncture & Moxibustion) 10: 23 24 (in Chinese with English abstract) 436 17 Beneficial Effect of Acupuncture on Depression Qiong Liu and Jin Yu Department of Integrative Medicine and Neurobiology Shanghai Medical College of Fudan University, Shanghai 200032, P. China Summary This chapter presents the clinical and laboratory evidence regarding the effect of acupuncture on depression and its potential mechanisms. Most of the clinical studies have demonstrated that either acupuncture alone or acupuncture combined with other therapies has a therapeutic effect on subjects with depression. The adverse effects were less and milder in the group under acupuncture treatment than in those under regular medication. Lastly, the hippocampus, an important brain structure that plays a key role in the etiology of depression, has been observed to be involved in the mechanism of acupuncture. Psychologist Martin Seligman addressed depression as the “common cold” of psychological problems, because nearly everyone suffers from it at some time point. Clinical depression is a real medical condition and is different from the term “being depressed” that is used frequently. It is a “whole-body” illness, involving the body, mood, and thoughts, which presents with depressed mood, loss of interest or pleasure, feeling of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. These symptoms linger, intensify, and lead to substantial impairments in an individual’s social functioning and/or activities of daily living. In other words, depression can interfere with a person’s normal functioning, and frequently disrupt the work, social, and family adjustment. It makes a person feel sad or hopeless most of the time and lose interest in things that were once enjoyed. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. People who suffer from depression usually struggle to do even the simplest things. The economic cost for this disorder is high, but the cost of human suffering cannot be estimated. It causes pain and suffering not only to those who have the disorder, but also to those who care about them. Serious depression can destroy family life as well as the life of the depressed person. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Psychological treatment of depression (psychotherapy) assists the depressed individual in several ways, which include supportive counseling, cognitive therapy, and problem-solving therapy. Some people with milder forms of depression may respond well to psychotherapy alone, while those with moderate to severe depression most often benefit from antidepressants. Most of the patients respond best to combined treatment: Medication—to gain relatively quick symptom relief, and psychotherapy—to learn more effective ways to deal with life’s problems, including depression. However, conventional treatments like psychotherapy and medication can alleviate the symptoms in a whopping 50% 70% of patients who complete the regimen; however, about one-third of the patients who begin therapy never complete it, because they may not observe any improvement or may experience debilitating side effects. Even among people who recover from depression, more than one-third revert back within 18 months. In addition, most empirically supported psychotherapies are also not readily available or affordable. Hence, there is a need for safe, effective, and affordable alternative treatments for depression. Acupuncture originated in China at least 3000 years ago, and moved to the west in the 1970s.

He and Dong (1983) observed that during acupuncture analgesia generic atomoxetine 10mg with mastercard medicine 54 357, the opioid activity increased in the human cerebrospinal fluid and the perfusate from certain brain regions buy atomoxetine 25mg free shipping medications given during dialysis. Zou et al (1979b discount atomoxetine 10 mg otc medicine app, 1980) found that acupuncture analgesia could be strengthened by applying an inhibitor to inhibit the extracellular degradation of enkephalin in the brain, which was associated with an increase in the level of enkephalin in the striatum, hypothalamus, as well as cerebrospinal fluid in the experimental animals. Furthermore, the release of dynorphin A1 13 was also observed to increase in the same nucleus. Interestingly, local injection of 106 4 Acupuncture-Induced Activation of Endogenous Opioid System naloxone was also found to antagonize the acupuncture effect. In contrast, the noradrenalin level in the plasma was not statistically different among the three groups. The ratio of leu-enkephalin and met- enkephalin remained unchanged when compared with that of the control group. There was no significant change in the content of enkephalin in other brain regions. In addition, in the rat model, they observed an increase in the contents of enkephalin in several brain regions. The ratio of leu-enkephalin and met- enkephalin was very different from that of the control group. Based on these results, it seems that acupuncture at different time points may differentially affect the contents of enkephalin in the brain. In an animal model of shock, Ma et al (1995) determined the contents of enkephalin in the brainstem, diencephalons, hypothalamus, striatum and hippocampus using radioimmunoassay, and observed that the traumatic shock tended to increase the level of leu-enkephalin in all these brain regions, while acupuncture decreased it in the hypothalamus. These receptors are distributed widely and distinctively in the central nervous system. They have a prominent role in brain function, as they regulate the reuptake and feedback of presynaptic transmitter and modulate various functions of the cell membrane. The simplest and strongest evidence is that many of the acupuncture effects can be eliminated or attenuated by the opioid receptor antagonists (Xia et al. Substantial data show that all the three major opioid receptors are involved in the acupuncture effects. There are also numerous reports showing that opioid receptor subtypes in the brain and spinal cord are differentially involved in producing acupuncture effects, depending on the experimental conditions and acupuncture effects tested (Fei et al. It is worth noting that some opioid receptors specifically participate in producing certain acupuncture effect, which varies with the brain regions. Some studies indicate that acupuncture-induced changes in the opioid receptor expression could also vary depending on the acupuncture conditions. In contrast, a slow and steady downregulation was found in the midbrain and striatum. Taken together, it seems that a mild and prolonged stimulation of acupuncture could increase the opioid receptor expression, while a strong and “over-long” stimulation may eventually lead to a decrease in the opioid receptor expression. At present, it is not well understood as to how acupuncture produces the thera- peutic effects on neurological disorders. The outcome information may potentially improve the clinical practice of acupuncture and provide novel insights into new solutions to some neurological disorders. Acupuncture and Electro therapeutics Research 8: 257 266 Herz A, Millan M (1989) Participation of opioids and opioid receptors in antinociception at various levels of the nervous system. China 3 Shanghai Research Center for Acupuncture and Meridians, Shanghai 201203, P. Acupuncture also regulates the expression and function of the corresponding receptors. However, the effects of acupuncture on the central neurotransmitters/modulators are dependent on the status of the organism and conditions of acupuncture (e. Although these data were largely obtained from the studies on acupuncture analgesia, it is reasonable to presume that acupuncture is capable of modulating the brain functions through the regulation of central neurotransmitters/modu-lators, because all the acupuncture-influenced neurotransmitters/modulators participate directly or indirectly in neural regulation in almost all aspects. Keywords neurotransmitters, modulators, monoamines, acetylcholine, amino acids 5 Effect of Acupuncture on Neurotransmitters/Modulators 5. Because of the unique nerve distribution and afferent pathway (see Chapter 2), specific acupoints, when stimulated by acupuncture or other approaches, may activate/inhibit certain neurotransmitters and modulators in various pathways. This chapter will summarize the progress in this field, except for the endogenous opioid peptides, which has been presented in Chapter 4. Owing to numerous earlier studies, we will make succinct description of the cited studies and present plumpish information in this short chapter. In the central nervous system, serotonin is believed to play an important role in the regulation of body temperature, mood, sleep, vomiting, sexuality, and appetite. However, their results were somewhat different from those of Takagi and Yonehara (1998), and this difference could be attributed to the different experimental conditions between their studies. The precursor tyrosine is transformed into dopamine by tyrosine hydroxylase, and the dopamine is subsequently transformed into noradrenalin by dopamine-ȕ- carboxylase. Noradrenalin is an important neurotransmitter of the post-ganglion sympathetic nerves and many central neurons, such as those in the locus ceruleus and hypothalamus. The released noradrenalin exhibits its effect by interacting with the adrenergic receptors. For example, through biochemical determination, Jin et al (1979) showed that acupuncture could decrease the content of noradrenalin in the rat brain. Some investigators suggest that acupuncture may change the rate of noradrenalin utilization and synthesis (Han et al. In an obese rat model, acupuncture also reduced the level of noradrenalin in the lateral hypothalamic area when inducing weight reduction. However, acupuncture may induce diverse effects in different brain areas in terms of the content of noradrenalin. Using histochemistry, Wei et al (1983a, 1983b) observed stronger noradrenalin staining in the posterior nucleus of the hypothalamus, lateral hypothalamic area, and intermediolateral nucleus of the spinal cord, after acupuncture treatment, while no significant change was found in the medial preoptic area of the hypothalamus and dorsal motor nucleus of the vagus nerve. Zhu et al (1984) showed that after the injection of glutamic acid sodium in the newborn rats to destroy arcuate nuclei, a major source of E-endorphin, acupuncture analgesia was significantly attenuated and the content of noradrenalin was higher in the brain of the experimental group than that in the control group. Destruction of the arcuate 125 Acupuncture Therapy of Neurological Diseases: A Neurobiological View nuclei along with the removal of pituitary gland, which greatly reduced the level of E-endorphin in the brain, further attenuated acupuncture analgesia and increased the content of noradrenalin in the brain. They observed that phentolamine could strengthen acupuncture analgesia, while noradrenalin could antagonize it. Till date, however, the noradrenalin receptor mechanism underlying acupuncture effects is not yet well understood. Currently, there is no convincing evidence to demonstrate the effect of acupuncture on the expression of noradrenergic receptors, though some reports suggest that acupuncture could alter the expression of noradrenergic receptors in the lung tissues of guinea pigs with asthma (Chen et al. Dopaminergic neurons uptake tyrosine and convert it to 3, 4 hydroxy-phenylalanine by the action of tyrosine hydroxylase, and subsequently to dopamine by the action of dopa decarboxylase.

N. Ingvar. Warner Pacific College.