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But major cause of people off-work etc Spinal movement is complex there are many components that could cause pain Not related to old age: most common in 25 60 year olds Patterns: Disc Pain Facet Joint Pain Nerve Root Pain Spinal Stenosis Location of Worst in back discount aurogra 100 mg mastercard erectile dysfunction after radiation treatment for prostate cancer. Pain worse bending backwards Presentation: midline pain radiating to groin or buttock buy discount aurogra 100mg on-line erectile dysfunction trials, worse towards the end of the day generic aurogra 100 mg line erectile dysfunction grand rapids mi, aggravated by coughing or sneezing discount aurogra 100mg on line erectile dysfunction keeping it up. Straight leg raising is normal Treatment: analgesics, physio, spinal fusion Acute lumbar disc prolapse: Nucleus pulposis extrudes into a fissure in the annulus and bulges beneath the posterior longitudinal ligament: Pressure on ligament back ache Pressure on dural envelope of the nerve root pain referred to lower limbs (sciatica) Compression of nerve root paraesthesia and muscle weakness Posture: stand forwards and sideways tilt Sudden onset lasting for hours/days. Local tenderness and loss of spinal mobility Differential: Inflammation (eg due to Ankylosing Spondylitis or Tb) Vertebral tumours constant pain Nerve tumours cause sciatic but constant pain X-ray to exclude bone disease. Conservative treatment Osteoporotic: painless or agonising localised pain that radiates around ribs and abdomen. Caution with spine physio: mechanical lever arm forces on vertebrae are very strong easy damage Psychogenic pain is a contributing factor in some. Look for signs of secondary gain Localisation of Lumbar Root Nerve Entrapment Nerve Root Usual prolapse Sensory Changes Reflex Loss Weakness L2 L2/L3 Front of thigh None Hip flexor and adductors L3 L2/L3 Inner thigh & knee Knee Knee extension L4 L4/L5 Inner calf Knee Knee extension L5 L4/L5 Outer calf, upper None Inversion, dorsiflexion inner foot of toes S1 L5/S1 Lateral borders/ sole Ankle Plantar flexion of foot Red Flags Continuous or progressive pain which doesnt change with movement Fever (e. Hemipelvis is unstable If >1 fracture then pelvic ring is unstable and up to 25% will have internal injuries. Look for painful arch from 60 120 due to insertion of inflamed rotator tendons catching on the acromion. Good test of glenohumeral joint (eg for frozen shoulder) Internal rotation: Test actively: place hand behind back and scratch as high as they can. Compare with good arm Extension is possible to 65 Testing Rotator Cuff: Pain worst at 90 abduction Supraspinatus: test abduction against resistance, especially from 0 - 30 (deltoid doesnt help much in that range) with thumbs pointing to the ground (turns the glenoid tubercle forward greater impingement) Musculo-skeletal 243 Infraspinatus: externally rotate against resistance Subscapularis: Lift-off test: Hold hand behind back, with patient pushing out from their back. May be due to osteophytes or narrowing under the coraco-acromial arch With age or injury the tendons of these muscles are prone to hyaline degeneration, fibrosis and calcification friction, swelling and pain. External rotation causes apprehension Fracture of Clavicle: Mechanism: fall on outstretched hand Clinical: arm clasped to chest to prevent movement, subcutaneous lump Xray: usually middle third Treatment: support arm in sling until pain subsides (2-3 weeks) A/C Joint: Mechanism: usually involves fall in which patient rolls on shoulder Clinical: Outer end of clavicle prominent, local tenderness present. Confirm subluxation by supporting elbow and detecting movement of clavicle downwards. May also be Horners syndrome Upper Arm and Elbow Exam In the elbow, look for: Joint effusion Musculo-skeletal 245 Lumps: rheumatoid nodules, gouty tophi, enlarge olecranon bursa Feel: especially for tenderness over the lateral epicondyle (tennis elbow) or medial epicondyle (golfers elbow) Move: Normal range is from 0 150. Limitation of extension early synovitis Radiology of elbow: If looking for effusion on an x-ray (eg blood in joint following fracture of the head of the radius) look for protrusion of the Haversian fat pads in the coronoid and olecranon fossa radiolucent triangles Avulsion of the medial epicondyle in children: Little leaguers injury from pitching in baseball Medial = Trochlear articulates with the ulnar (literally = pulley) Lateral = Capitalum articulates with the radius Injury Fracture of proximal humerus: Mechanism: Fall on outstretched arm, most common in post menopausal women Clinical: Appearance of large bruise on upper arm. Begin mobilising early as pain permits: gentle arm swinging, climbing fingers up the wall. Arm is blue, there is no radial pulse and passive finger extension is painful (the key sign) Cast in < 90 flexion Fractured Head of Radius: Mechanism: fall on outstretched hand forces elbow into valgus. Common in adults Clinical: Painful rotation of forearm, tender on lateral side of elbow Treatment: Sling Fractures of Olecranon: Mechanism: Direct blow or fall on elbow causes a comminuted fracture. Clean transverse break is due to traction when patient falls on hand whilst triceps contracted (attaches to olecranon) Clinical: Graze or bruise over elbow. With a transverse fracture there may be a palpable gap and they are unable to extend elbow against resistance Treatment: Undisplaced transverse needs immobilisation in cast at 60 degrees flexion for 2-3 weeks then exercises begun Pulled Elbow: Mechanism: Radial head stretching annular ligament and slipping out from under its cover. Usually kids 2 6 years old when parents have pulled on childs arm (esp when crossing road) Clinical: Tenderness over lateral aspect, supination limited Treatment: Sling, usually results in spontaneous reduction Tennis Elbow: enthesitis of the common extensor origin on the lateral epicondyle of the humerus pain on contraction/stretching of the forearm extensors. Squeeze a partly inflated sphygmomanometer Key grip: try and pull thumb and forefinger apart Opposition: try and pull thumb and little finger apart Functional test: undo a button, write with a pen Testing nerves: Want to test intrinsic muscles that have no extrinsic help Ulnar Nerve (Medial cord, C8, T1) Abductor of little finger Adductor pollicis: grip paper between thumb and side of index finger and try and pull it away. Weakness of the long finger extensors, short and long thumb extensors but no sensory loss. Posterior Cutaneous branch supplies a variable area on the back of the arm and forearm Common sites affected: axilla (eg pressure from crutches), midhumeral fracture, at and below the elbow (dislocations and Monteggia fractures) Testing ligaments: Ligaments: test like knee. Twisting may cause spiral or oblique fractures at different levels Clinical: Fracture usually obvious. Wrist and hand must be examined for signs of injury to radial nerve Treatment: Restore length to ulna then reduce. Deformity and radiology also often definitive Treatment: If displaced then reduce, plaster cast in ulnar deviation and slight flexion for 5-6 weeks with finger and wrist exercises Complications: Radial drift or ulna prominence in mal union. Delayed rupture of tendon of extensor pollicis longus due to roughness at site of injury or decreased blood supply ( Mallet thumb). Carpal tunnel syndrome also possible Smiths Fracture: Due to fall on the back of hand. Reverse of Colles fracture (ie volar displacement rather than dorsal) Bartons Fracture: Intra-articular fracture of the distal radius. Collies cast, with thumb free, up to 10 weeks to healing) may not see it on first Xray and prone to non-union. Lunate stays attached to radius, all other carpals pushed dorsally Trans-scaphoid perilunate dislocation: as for perilunate dislocation, but fracture through the waist of the scaphoid leaves the proximal fragment in place. Following a fall or blow on a clenched fist or forced abduction of the thumb (skiers). Unstable as oblique and proximal fragment is attached to trapezium and distal fragment has strong muscles attached to it that pull it proximally. Transverse fracture is straightforward: Scaphoid cast Multiple metacarpal fractures: twisting and crush injuries. Finckelsteins sign: pain on forcible adduction and flexion of the thumb into the palm. Stenosing tenosynovitis/inflamed tendon sheath of extensor pollicis brevis and abductor pollicis longus. If unstable (cant oppose fingers) then repair (adductor tendon may get in the way and prevent reattachment) Dislocation of the phalanges: usually always ligament injury as well. Buddy strapping + early mobilisation Phalangeal fractures: Buddy taping: encourage flexion, deny rotation, allow for swelling (ie not too tight) Dupuytrens Contracture: Painless fibrosis of the palmar aponneurosis (can also occur on the foot). Usually familial (associations with alcoholism and manual work over-rated), anti-epileptics. Causes puckering of the skin over the distal palmar crease and gradual flexion of the fingers (usually starts with ring finger). Prognosis worse if younger Ganglia: Painless, jelly filled swelling caused by a partial tear or bulging of a joint capsule. Carpal Tunnel Syndrome Compression of the median nerve as it passes through the carpal tunnel in the wrist Epidemiology: Common. Usually women 3 - 50 years Causes: Due to thickened tendons or synovitis in the carpal tunnel Rheumatoid arthritis Hypothyroidism Acromegaly nd Pregnancy (2 ary to oedema) Obesity Amyloid Diabetes Mellitus Idiopathic Symptoms: Pain/tingling in the hand and wrist classically in the median nerve distribution (palm and thumb, index and middle fingers). Wakes at night, shakes hand, cant get it comfortable Musculo-skeletal 249 Signs: Wasting of thenar eminence, weak thumb abduction and opposition (late signs). Quads contract to prevent buckling of the knee Foot Flat: Dorsiflexors slowly relax to bring foot to ground, and hip extensors propel body forward Mid stand: body directly over ankle Heel off: Triceps surae contract Toe off: Hallucis and flexor digitorum longus contract Swing phase (40% of the cycle): Acceleration: iliopsoas contracts (flexes hip), passive knee extension, dorsiflexors contract so foot clears the ground Mid swing Deceleration: hamstrings stop hyper-extension of the knee and gluteus maximus slows hip flexion Double stance: both feet on ground for 20% of the cycle when walking. When running this % reduces to 0% (ie swing > 50% of cycle so both feet off the ground at some point) Abnormalities of Gait Causes a limp The main causes of abnormal gait are: Pain Antalgic gait (non-specific). Pain shortened stance phase on affected leg, shortened swing of opposite leg Weakness Joint abnormality Usually noticed during stance phase when one leg is bearing the bodys weight Swing phase: Abnormal heel strike due to: Pain in hind foot (so land on forefoot) Quad weakness: Knee wont extend by itself, so lands flexed and at risk of buckling. Use hand to push thigh posteriorly (foot and hip fixed so backward pressure on distal thigh stops the knee collapsing). Look at hip and shoulder alignment Extensor Lurch or Gluteus Maximus Gait: Dont have enough strength in gluteus maximus to hold hip in extension risk that the torso collapses forward at the end of stance. Lurch torso backwards to compensate Flat Foot or Calcanial Gait: cant toe-off, instead lift whole foot off without extending big toe.
Vitamin B12 is initially bound to an R factor present in saliva purchase aurogra 100mg amex erectile dysfunction aids, which stabilizes B12 in acidic gastric pH cheap aurogra 100mg online erectile dysfunction pump australia. Pancreatic enzymes release the R factor from B12 to allow B12 to bind to the intrinsic factor secreted by the stomach aurogra 100 mg discount erectile dysfunction pills at gas stations, which is required for B12 absorption at the terminal ileum generic aurogra 100 mg overnight delivery erectile dysfunction caused by low testosterone. It is elevated during an attack of pancreatitis and in renal failure, and is decreased in severe pancreatic insufficiency, cystic fibrosis and insulin-dependent diabetes without exocrine insufficiency. The levels of trypsinogen in cystic fibrosis decrease with age if the pancreas is involved. Patients with pan- creatic insufficiency who have ongoing inflammation may have normal or raised levels. This fact, in addition to low levels in noninsulin-dependent diabetes, casts some doubt on the usefulness of this test in diagnosing pancreatic insufficiency. It may be useful in patients with steatorrhea that is due to nonpancreatic causes. Amylase is produced and released from a variety of tissues, including the salivary glands, intestine and genitourinary tract. Normal serum contains three types of isoamylases as identified by isoelectric focusing. Electrophoresis on polyacrylamide gel can separate five isoamylases on the basis of electrode mobility. Amylases originating in the fallopian tubes, tears, mucus and sweat have the same mobility as salivary amylase. All amylases have similar molecular weight and amino acid composition, but vary in terms of their glycosylation or deamination. Amylase is filtered through the glomerular membrane and is reabsorbed in the proximal tubule. During acute pancreatitis, there is an increase in amylase clearance as opposed to creatinine clearance. Although this ratio was once thought to be specific to acute pancreatitis, other conditions that produce hyperamylasemia (such as diabetic ketoacidosis, burns, renal failure and per- forated duodenal ulcer) may demonstrate a similar elevation. Occasionally, the serum amylase may be markedly increased in the absence of pancreatic or salivary diseases, whereas the urinary amylase is normal. In the latter condition normal serum amylase is bound by an immunoglobulin A (IgA), forming a complex that is too large to be filtered by the glomerulus. Affected individu- als have an elevated serum amylase and a low to normal urinary excretion rate. Frequently physicians are faced with a patient who has no overt salivary gland disease but has hyperamylasemia and no specific abdominal findings. As a rule, the level of amylase in pancreatitis usually is elevated to greater than 3 times the upper limit of normal and returns to normal within 2 to 10 days. If the amylase continues to be elevated in the absence of pancreatic complications, other causes (such as malignancy and macroamylasemia) should be investigated. A rapid rise and fall in serum amylase in a patient with abdominal pain suggests the passage of a stone through the ampulla of Vater. When the serum amylase remains elevated for several days, the gallstone disease is usually complicated by pancreatitis. Marked hyperamylasemia has been observed in patients with metastatic disease with ovarian cysts and tumors, and in ruptured ectopic pregnancy. Isoamylase analysis reveals that the amylase has the same electrophoretic mobility as salivary-type isoenzyme. Macroamylase consists mostly of salivary amylase complexed with globulins, being therefore too large to be filtered at the glomerulus. Therefore these individuals have elevated serum amylase and low urinary amylase, with a low amylase-to-creatinine clearance ratio. While the amylase levels in serum and urine are usually used as a measure of acute pancreatitis, measurements of lipase may be more specific and sensitive than total serum amylase. The assay of lipase is as accurate as the pancreatic isoamylase assay, and is likely to replace the amylase assay. Amylase and lipase measurements are readily available clinically, whereas radioimmunoassays are still being developed for other pancreatic enzymes (such as trypsin, chymotrypsin and elastase). Shaffer 597 A recently developed urinary test for trypsinogen-2, which can be done with a urinary dipstick, appears to be quite promising in detecting patients with acute pan- creatitis. It has a sensitivity of 94% and a specificity of 95%, as compared to serum amylase assay which has a sensitivity of 85% and a specificity of 91%. Pancreatitis tends to present with abdominal pain, which may improve with no sequelae or may run a more severe course that can lead to death. When the pancreas is continuously injured, such as with alcohol, a chronic condition results in obstruction and fibrosis of the gland, which leads to pancreatic insufficiency and chronic pain. Even one attack of pancreatitis from alcohol use can lead to some residual pancreatic damage. Inadvertent activation of trypsin and chemotrypsin in the pancreas is normally prevented by several protective mechanisms; these are overwhelmed in acute pancreatits, resulting in autodigestion. Trypsin and chymotrypsin are the initiating enzymes; their release can in turn result in the release and activation of other proenzymes (including proelastase, procolla- genase and phospholipases). Trypsin damages endothelial cells and mast cells, resulting in the release of histamine. This major inflammatory mediator enhances vascular permeability, leading to edema, hemorrhage and the activation of the kallikrein system, which in turn results in the production of vasoactive peptides or kinins. The latter are thought to cause pain and further aggravate the inflammatory response. The other released enzymes destroy the supporting matrix of the gland and the plasma membrane of the acinar cell, precipitating further release of digestive enzymes, which in turn leads to further damage. Lysolecithin, which is released by the action of phospholipase on lecithin (a phospholipid found in bile), has also implicated in pancreatic damage, because of its cytotoxic and haemolytic properties. Although the action of these enzymes results in pancreatic damage, the triggering mechanism is not well known. In the case of gallstone pancreatitis, major theories include (1) reflux of bile into the pancreatic duct (2) distal obstruction of the pancreatic duct by stones or oedema from recent stone passage. When the pancreas is inflamed but remains viable, the condition is termed interstitial pancreatitis; this may occur in up to 80% of cases. In the remaining cases, there is a significant pancreatic necrosis resulting from disruption of the microcirculation, destruction of the pancreatic parenchyma and peripancreatic necrosis. This latter condition, necrotizing pancreatitis, follows a more protracted course. In the case of gallstones, the major theories include (1) reflux of bile into the pancreatic duct; and (3) distal obstruction of the First Principles of Gastroenterology and Hepatology A. Shaffer 598 pancreatic duct, with continued pancreatic secretion leading to increased ductal pressure and resulting in pancreatitis. Although alcohol has been implicated as a major cause of acute pancreatitis in at least 30% of cases, there is no evidence that an occasional bout of excessive alcohol intake can lead to an acute attack.
Diagnostic value of haemoglobin A1c in post- abnormal glucose tolerance test value mimic gestational diabetes mellitus? Utility of early postpartum glucose tolerance mal glucose tolerance among women with gestational diabetes mellitus: Diag- testing buy 100mg aurogra free shipping food that causes erectile dysfunction. Role of HbA1c in post-partum screen- ment in women with prior gestational diabetes order generic aurogra line erectile dysfunction treatment hyderabad. Recurrence of gestational diabetes mellitus: type 2 diabetes: A systematic review generic aurogra 100mg mastercard erectile dysfunction causes smoking. The impact of ethnicity on glucose risk for the development of diabetes mellitus in the early puerperium in women regulation and the metabolic syndrome following gestational diabetes buy aurogra 100 mg amex kidney disease erectile dysfunction treatment. Prior gestational hyperglycemia: A long- betes risk in women with gestational diabetes: A systematic review and meta- term predictor of the metabolic syndrome. Gestational diabetes: The signicance of persistent mellitus is three-fold higher than in the general population. J Clin Endocrinol fasting hyperglycemia for the subsequent development of diabetes mellitus. Long term prognosis of women with bolic syndrome and insulin resistance in women with previous gestational dia- gestational diabetes in a multiethnic population. Postgrad Med J 2007;83:426 betes mellitus by International Association of Diabetes in Pregnancy Study 30. Gestational diabetes mellitus and later nancy and future risk of diabetes in young women. Gestational diabetes identies women partum assessment of women with gestational diabetes mellitus. Diabetes Metab at risk for permanent type 1 and type 2 diabetes in fertile age: Predictive role Syndr 2007;1:15965. Gestational diabetes mellitus increases patients with gestational diabetes mellitus. Postpartum diabetes screening associated with risk of progression from gestational diabetes mellitus to type 2 in women with a history of gestational diabetes. Interventions to modify the progres- guideline recommendation to screen for type 2 diabetes in women with ges- sion to type 2 diabetes mellitus in women with gestational diabetes: A sys- tational diabetes change practice? Participation in physical activity: Perceptions tralian women with a recent history of gestational diabetes mellitus. Understanding exercise beliefs and behaviors mellitus screening rates in patients with history of gestational diabetes. Diabetes screening after gestational dia- spective, randomized, clinical-based, Mediterranean lifestyle interventional study betes in England: A quantitative retrospective cohort study. Reminder systems for women with previous ges- ciation with birth weight, maternal obesity, and gestational diabetes melli- tational diabetes mellitus to increase uptake of testing for type 2 diabetes or tus. Original research: Postpartum testing rates among childhood overweight and obesity in offspring: A systematic review. Diabetologia glucose testing and sustained glucose dysregulation after gestational diabe- 2011;54:195766. Mild gestational diabetes mellitus and of gestational diabetes mellitus: A report from the Translating Research Into long-term child health. The importance of postpartum glucose tol- with gestational diabetes mellitus in a low-risk population. Maternal metabolic conditions and Citations identified through Additional citations identified risk for autism and other neurodevelopmental disorders. Contraception and the risk of type 2 diabe- Citations after duplicates removed tes mellitus in Latina women with prior gestational diabetes mellitus. Recurrence of gestational diabetes mel- Title & abstract screening Citations excluded* litus. A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mor- tality and malformation rates to general population levels. Glycaemic control during early for eligibility N=502 pregnancy and fetal malformations in women with type I diabetes N=713 mellitus. Glycaemic control is associated with pre- N=211 eclampsia but not with pregnancy-induced hypertension in women with type I diabetes mellitus. Strategies for reducing the frequency of pre- eclampsia in pregnancies with insulin-dependent diabetes mellitus. Central nervous system and limb anomalies in case reports recommendations of rst-trimester statin exposure. A randomized trial comparing peri- natal outcomes using insulin detemir or neutral protamine Hagedorn in type 1 diabetes. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classi- cation of hyperglycemia in pregnancy. Can J Diabetes 42 (2018) S283S295 Contents lists available at ScienceDirect Canadian Journal of Diabetes journal homepage: www. There are many people with type 2 diabetes who are over the age of 70 Diabetes in older people is distinct from diabetes in younger people and who are otherwise well, functionally independent/not frail and have the approach to therapy should be different. These people should who have functional dependence, frailty, dementia or who are at end of life. Personalized strategies are be treated to targets and with therapies described elsewhere in this needed to avoid overtreatment of the frail elderly. S42 and Phar- In the older person with diabetes and multiple comorbidities and/or frailty, macologic Glycemic Management of Type 2 Diabetes in Adults strategies should be used to strictly prevent hypoglycemia, which include chapter, p. This chapter focuses on older people who do not the choice of antihyperglycemic therapy and a less stringent glycated hemo- globin (A1C) target. Decisions regarding therapy Sulphonylureas should be used with caution because the risk of hypogly- should be made on the basis of age/life expectancy and the persons cemia increases signicantly with age. S10, glycated No two older people are alike and every older person with diabetes needs hemoglobin (A1C) can be used as a diagnostic test for type 2 dia- a customized diabetes care plan. Unfortunately, normal aging is associated with a pro- the best course of treatment for another. Some older people are healthy and can manage their diabetes on their own, while others may have 1 or gressive increase in A1C, and there can be a signicant discordance more diabetes complications. Others may be frail, have memory loss and/or between glucose-based and A1C-based diagnosis of diabetes in this have several chronic diseases in addition to diabetes. Because they are complementary, we recommend screening with both a fasting plasma glucose and an A1C in older people. Introduction In the absence of positive intervention studies on morbidity or mor- tality in this population, the decision about screening for diabetes This guideline refers primarily to type 2 diabetes in the older should be made on an individual basis. There is limited information on the management of type 1 benecial in most people over the age of 80.
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Adverse events of apomorphine formulations for erectile dysfunction: associated with testosterone replacement in middle- Recommendations for use in the elderly. Drugs Aging aged and older men: A meta-analysis of randomized, 2006;23(4):309-319. Journals of Gerontology Series A-Biological Sciences & Medical Sciences Briganti A, Salonia A, Zanni G et al. Beneficial cardiovascular effects and safety of sildenafil reported in trio of studies. Clinical & Experimental Pharmacology & Physiology Relationship between patient self-assessment of 2007;34(4):327-331. Testosterone and erectile function, nocturnal penile tumescence and Brown J S, Wessells H, Chancellor M B et al. Urologic rigidity, and erectile response to visual erotic stimuli complications of diabetes. The effects of testosterone administration and visual erotic stimuli on Buddeberg C, Bucher T, Hornung R. 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