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By U. Dolok. Oregon Health Sciences University.

Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children buy generic proscar 5 mg online prostate 100 grams. As outlined above 5mg proscar otc prostate 90 grams, the population and the clinical problem define the initial presentation and referral filter. In addition, a key question is whether we are evaluating the test to assess whether it should replace an existing test (because it is better, or just as good and cheaper) or to assess whether it has value when used in addition to a particular existing test. This decision will also be a major determinant of how the data will be analysed. To what extent do you want to study the reasons for variability of the results within your population? Data should be presented on the amount of variability between different readers or test types and tools to help calibration, such as standard radiographs,39,40 or laboratory quality control measures. The extent to which other factors, such as experience or training, affect reading adequacy will also help guide readers of the study. Assessment of variability should include not only test discriminatory power but also calibration, if the objective is to provide study results that are useful for individual clinical decision making. Do the findings vary in different (prespecified) subgroups within the study population? Data should be analysed to determine the influence on test performance characteristics of the following variables, which should be available for each individual. These can be considered separately by users or combined into a weighted specificity for different settings. The same approach can be used for levels (stage, grade) in the “diseased” group. It should take account of logical sequencing of tests (simplest, least invasive, and cheapest are generally first). It should also take account of possible effect modification by other tests. In some instances people would have been referred because of other tests being positive (or negative), so that the incremental value of the new test cannot be evaluated. In this case, knowing the referral filter and how tests have 111 THE EVIDENCE BASE OF CLINICAL DIAGNOSIS been used in it (as in Figure 6. For example, a study by Flamen31 has shown that the major value of PET for recurrent colorectal adenocarcinoma is in the category of patients in whom prior (cheaper) tests gave inconclusive results. It would therefore be a useful incremental test in that category of patients, but would add little (except cost) if being considered as a replacement test for all patients, many of whom would have the diagnostic question resolved by the cheaper test. There are often a vast number of characteristics that could be used to define subgroups in which one may wish to check whether there are differences in test performance. The essential descriptors of a clinical situation need to be decided by the researcher. As for subgroup analysis in randomised trials,47 these characteristics should be prespecified, rather than decided at analysis stage. The decision is best made on the basis of an understanding of the pathophysiology of the disease, the mechanism by which the test assesses abnormality, an understanding of possible referral filters, and knowledge of which characteristics vary widely between centres. Remember that variability between test characteristics in subgroups may not be due to real subgroup differences if there is reference standard misclassification and the prevalence of disease differs between subgroups, as shown in Table 6. Modelling techniques can be used to assess the effect of several potential predictors of test accuracy simultaneously. To what extent do you want to study the transferability of the results to other settings? To address this question, you need to perform the study in several populations or centres, and assess the extent to which test performance differs, as has been done for the General Health Questionnaire53 and predictors of coma. Predictors (as discussed above) should also be measured to assess the extent to which within-population variables explain between-population variability. Because of the low power of tests of heterogeneity, this is worth doing even if tests for heterogeneity between centres or studies are not statistically significant. The more the measured variables explain between-population differences, the more they can be relied on when assessing the transferability of that study to the population in the reader’s setting. Between-site variability can also be explored across different studies using meta-analytical techniques.

The genital branch runs in the abdominal wall along the inguinal ligament Lumbar Plexus through the inguinal canal and reaches the scrotum with the spermatic cord or cheap proscar 5mg on line prostate cancer 7 on gleason scale, in the The lumbar plexus gives off direct short female proscar 5mg low price mens health june 2013, the labia majora with the round muscular branches to the hip muscles, ligament of the uterus. It innervates the namely, to the greater and lesser psoas cremaster muscle and supplies sensory muscles (L1–L5), the lumbar quadrate fibers to the skin of the scrotum, or the labia muscle (T12–L3), and the lumbar inter- majora, respectively, and the adjacent skin costal muscles. The plexus are still roughly organized in the femoral branch continues to below the in- same way as the intercostal nerves. To- guinal ligament and becomes subcutaneous gether with the subcostal nerve (A7), they in the saphenous hiatus. It supplies the skin represent transitional nerves between the of the thigh lateral to the region of the geni- intercostal nerves and the lumbar nerves. The iliohypogastric nerve (A8) initially runs A12Posterior cutaneous nerve of femur on the inside of the lumbar quadrate muscle (p. It gives off two main branches, namely, the lateral cutaneous branch which supplies the lateral hip region, and the anterior cu- taneous branch which penetrates the aponeurosis of the external oblique muscle of the abdomen cranially to the outer ingui- Kahle, Color Atlas of Human Anatomy, Vol. Lumbosacral Plexus 87 L 1 L 2 7 L 3 8 L 4 9 11 10 L 5 2 3 S 1 14 S 2 S 3 S 4 S 5 Cocc. The muscular branches al- ways ramify into several branches for the Lateral Cutaneous Nerve of Thigh (L2–L3) proximal and distal portions of the muscles. Fibers then extends underneath the inguinal liga- from the branch for the medial vastus ment through the lateral part of the muscu- muscle extend to the femoral artery and lar lacuna to the outer aspect of the thigh femoral vein. Below the knee joint, it gives off the supplies the skin of the lateral aspect of the infrapatellar branch (B–D15) which sup- thigh down to the level of the knee. Theremain- ing branches, the medial crural cutaneous Femoral Nerve (L1–L4) (B–D) branches, supply the skin of the anterior and The nerve runs along the margin of the medial aspects of the lower leg. The sup- greater psoas muscle up to the inguinal liga- plied area extends on the anterior side over mentandunderneathitthroughthemuscu- the edge of the tibia and may reach to the larlacunatothefrontofthethigh. Flexion in the hip joint is reduced, and the patellar tendon reflex is absent. The saphenous nerve extends to zone (dark blue) and maximum zone (light the adductor canal and enters into it. In the small pelvis, the femoral nerve gives off fine branches (D3) to the greater psoas muscle (B4) and to the iliac muscle (B5). Below the inguinal ligament, a branch (D6) extends to the pectineal muscle (B7). The anterior cutaneous branches (B–D1) origi- nate slightly more distally, with the strongest one continuing along the middle of the thigh down to the knee. They supply sensory fibers to the skin of the anterior and medial aspects of the thigh. The lateral group of branches (D8) consists of muscularbranches for the sartorius muscle (B9), the rectus femoris muscle (B10), the lateral vastus muscle (B11), and the inter- mediate vastus muscle (B12). The muscular branch (D13) for the medial vastus muscle (B14) runs along the medial margin of the Kahle, Color Atlas of Human Anatomy, Vol. Lumbar Plexus 89 1 A Skin supplied by the lateral cutaneous nerve of thigh 15 (according to Lanz-Wachsmuth) L 1 2 4 L 2 L 3 5 L 4 1 7 3 9 6 C Skin supplied by the femoral nerve (according to Lanz- 2 Wachsmuth) 12 13 1 10 11 2 8 14 15 D Sequence of branches 15 B Muscles supplied by the femoral nerve (according to Lanz-Wachsmuth) Kahle, Color Atlas of Human Anatomy, Vol. Standing on the affected leg Obturator Nerve (L2–L4) and lifting the healthy leg makes the pelvis of the other side drop (Trendelenburg’s symptom). Medial to the greater psoas muscle, it extends along the Inferior Gluteus Nerve (L5–S2) (F) lateral wall of the small pelvis down to the The nerve leaves the pelvis through the in- obturator canal through which it passes to frapiriform foramen and gives off several reach the thigh. It gives off a muscular branches to the gluteus maximus muscle branch to the external obturator muscle (F14). The superficial Clinical Note: Paralysis of the nerve weakens branch (AB2) runs between the long adduc- extension of the hip joint (for example, when tor muscle (A3) and short adductor muscle standing up or climbing stairs). The nerve also gives off branches to the pectineal muscle and the gracilis muscle (A5) and finally ter- Posterior Cutaneous Nerve of Thigh minates in a cutaneous branch (A–C6) to the (S1–S3) (D) distal region of the medial aspect of the The nerve leaves the pelvis together with thigh. The deep branch (AB7) runs along the sciatic nerve and inferior gluteus nerve external obturator muscle and then down to through the infrapiriform foramen and the great adductor muscle (A8). Located Clinical Note: Paralysis of the obturator nerve directly beneath the fascia lata, it extends (for example, as a result of pelvic fracture) causes along the middle of the thigh into the pop- loss of adductor muscle function. This exclusively sensory nerve standing and walking, and the affected leg can no longer be crossed over the other leg.

A urinalysis can be important in the diagnosis of several en- docrine disorders purchase 5mg proscar amex mens health june 2012. A high level of glucose in a fasting patient in- dicates diabetes mellitus proscar 5mg amex androgen hormone negative feedback. A patient who has diabetes insipidus will produce a large volume (5–10 L per day) of dilute urine of low specific gravity. Certain diseases of the adrenal glands can also be detected by examining for changes in urine samples col- Simmonds’ disease: from Morris Simmonds, German physician, 1855–1925 lected over a 24-hour period. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 Chapter 14 Endocrine System 481 (a) (b) (c) FIGURE 14. This disorder affects body fluids, causing edema and increasing Symptoms of this disease include polyuria (excessive urination), blood volume, hence increasing blood pressure. A person with polydipsia (consumption of large amounts of water), and severe ionic myxedema has a low metabolic rate, lethargy, sensitivity to cold, imbalances. This condition is treated with thyroxine or triiodothyronine, both of which are taken orally. Disorders of the Thyroid Endemic Goiter and Parathyroid Glands A goiter is an abnormal growth of the thyroid gland. When this is a result of inadequate dietary intake of iodine, the condition is Hypothyroidism called endemic goiter (fig. An affected child usually appears normal at birth levels of thyroxine secretion. Endemic goiter is thus associated because thyroxine is received from the mother through the pla- with hypothyroidism. The clinical symptoms of cretinism are stunted growth, thickened facial features, abnormal bone development, mental retardation, low body temperature, and general lethargy. If cre- Graves’ Disease tinism is diagnosed early, it can be successfully treated by admin- Graves’ disease, also called toxic goiter, involves growth of istering thyroxine. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 482 Unit 5 Integration and Coordination FIGURE 14. Type I, or insulin-dependent diabetes mellitus, is hyperthyroidism is produced by antibodies that act like TSH and caused by destruction of the beta cells and the resulting lack of stimulate the thyroid; it is an autoimmune disease. Type II, or non-insulin-dependent diabetes quence of high levels of thyroxine secretion, the metabolic rate mellitus (which is the more common form), is caused by de- and heart rate increase, there is loss of weight, and the auto- creased tissue sensitivity to the effects of insulin, so that increas- nomic nervous system induces excessive sweating. Treatment of advanced diabetes mellitus requires adminis- tering the necessary amounts of insulin to maintain a balanced Disorders of the Parathyroid Glands carbohydrate metabolism. If excessive amounts of insulin are Surgical removal of the parathyroid glands sometimes uninten- given, the person will experience extreme nervousness and tionally occurs when the thyroid is removed because of a tumor tremors, perhaps followed by convulsion and loss of conscious- or the presence of Graves’ disease. This condition, commonly called insulin shock, can be roid hormone (PTH) causes a decrease in plasma calcium levels, treated by administering glucose intravenously. Hyperparathyroidism is usually caused by a tumor that secretes excessive amounts of Reactive Hypoglycemia PTH. This stimulates demineralization of bone, which makes the bones soft and raises the blood levels of calcium and phosphate. People who have a genetic predisposition for type II diabetes As a result of these changes, the bones are subject to deformity mellitus often first develop reactive hypoglycemia. In this condi- and fracture, and stones composed of calcium phosphate are tion, the rise in blood glucose that follows the ingestion of carbo- likely to develop in the urinary tract. This can result in weakness, changes in personality, and exophthalmos: Gk. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 Chapter 14 Endocrine System 483 Disorders of the Adrenal Glands ple with chronic inflammatory diseases receive prolonged treat- ment with corticosteroids, which are given to reduce inflamma- tion and inhibit the immune response. These tumors cause hypersecretion of epinephrine and norepinephrine Usually associated with Cushing’s syndrome, this condition is whose effects are similar to those of continuous sympathetic ner- caused by hypersecretion of adrenal sex hormones, particularly vous stimulation. Adrenogenital syndrome in young children causes sion, elevated metabolism, hyperglycemia and sugar in the urine, premature puberty and enlarged genitals, especially the penis in nervousness, digestive problems, and sweating. An increase in body hair and a long for the body to become totally fatigued under these condi- deeper voice are other characteristics. This condition in a mature tions, making the patient susceptible to other diseases.

J Shoulder Elbow Surg 7:100-108 lonodular synovitis and related lesions: the spectrum of imag- Yu JS order 5mg proscar visa mens health grooming awards, Greenway G cheap 5mg proscar with visa prostate cancer options for treatment, Resnick D (1998) Osteochondral defect of the ing findings. Am J Roentgenol 172:191-197 glenoid fossa: Cross-sectional imaging features. Radiology Linker CS, Helms CA, Fritz RC (1993) Quadrilateral space syn- 206:35-40 drome: evaluation of median nerve circulation with dynamic Zanetti M, Weishaupt D, Jost B, Gerber C, Hodler J (1999) MR contrast-enhanced MR imaging. Radiology 188:675-676 imaging for traumatic tears of the rotator cuff: High prevalence McCarty DJ, Halverson PB, Carrera GF et al (1981) “Milwaukee of greater tuberosity fractures and subscapularis tendon tears. Steinbach2 1 University of California, San Diego, and VAHCS, CA, USA 2 Musculoskeletal Imaging, University of California San Francisco, San Francisco, CA, USA Elbow injuries are common, especially in the athlete, and impaction and shearing forces applied to the articular sur- can be basically classified into acute or chronic injuries. The overall configuration of the humeroradial ar- The following discussion of magnetic resonance imaging ticulation, in this case, can be likened to a mortar and (MRI) of the elbow will address variations in normal pestle, with the capitellar articular surface impacting that anatomy that represent pitfalls in imaging diagnosis, and of the radius to result in a chondral or osteochondral le- commonly encountered osseous and soft-tissue pathology. These acute post-traumatic lesions are manifested on MRI as irregularity of the chondral surface, disruption or irregularity of the sub- Osseous Anatomic Considerations and Pathology chondral bone plate, and or the presence of a fracture line. The acuity of the lesion and a post-traumatic etiolo- The lateral articulating surface of the humerus is formed gy are implied by the presence of marrow edema and by the capitellum, a smooth, rounded prominence that joint effusion. Close inspection of the location of the le- arises from its anterior and inferior surfaces. As it does sion on coronal and sagittal MRI is of the utmost impor- so, its width decreases from anterior to posterior. This tance in order to distinguish a true osteochondral lesion morphology of the capitellum (smooth surface), in con- from the pseudodefect of the capitellum. Correlation with junction with the knowledge that the adjacent lateral epi- presenting clinical history is also helpful in determining condyle (rough surface) is a posteriorly oriented osseous the etiology of imaging findings. Osteochondritis dissecans is thought the configuration of a figure of eight. At the waist of the to occur in immature athletes between 11 and 15 years of eight, or junction between anterior and posterior aspects age, rarely in adults. Osteochondritis dissecans of the of the ulna, the articular surface is traversed by a carti- elbow involves primarily the capitellum, but reports have lage-free bony ridge. This trochlear ridge is 2 to 3 mm described this process in the radius and trochlea. It should not be mistaken for a central os- the role of imaging is to provide information regarding the teophyte. The waist of the figure of eight is formed by the integrity of the overlying articular cartilage, the viability tapered central surfaces of the coronoid and olecranon of the separated fragment, and the presence of associated processes both medially and laterally, forming small cor- intra-articular bodies. On sagittal MRI, these and MRI with and without arthrography can provide this focal regions devoid of cartilage could be mistaken for a information to varying degrees, although no scientific in- focal chondral lesion. MRI, with its excellent Osteochondral Lesions soft-tissue contrast, allows direct visualization of the ar- ticular cartilage, as well as of the character of the interface In the case of acute medial elbow injury, the involvement of the osteochondral lesion with native bone (Fig. The of a valgus force is usually described as one of the most presence of joint fluid or granulation tissue at this inter- common mechanisms of injury. Subchondral bone face, manifested as increased signal intensity on fluid-sen- and cartilage injuries that occur in this setting result from sitive MRI, generally indicates an unstable lesion. Steinbach a troduction of contrast into the articulation in conjunction with MRI can be helpful in two ways: (1) to facilitate the identification of intra-articular bodies, and (2) to establish communication of the bone-fragment interface with the articulation by following the route of contrast, providing even stronger evidence for an unstable fragment [6, 7]. Ligament Pathology Valgus Instability The principle function of the ulnar collateral ligament com- plex is to maintain medial joint stability to valgus stress. The anterior bundle is the most important component of the lig- amentous complex to this end, as it serves as the primary me- dial stabilizer of the elbow from 30 to 120 degrees of flex- ion. The most common mechanisms of ulnar collateral liga- ment insufficiency are chronic attenuation, as seen in over- b head or throwing athletes, and post-traumatic, usually after a fall on the outstretched arm. In the case of the latter, an acute tear of the ulnar collateral ligament may be encountered. With throwing sports, high valgus stresses are placed on the medial aspect of the elbow. The maximum stress on the ulnar collateral ligament occurs during the late cocking and acceleration phases of throwing.

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