By R. Jaroll. The College of New Jersey.

Even if Current Trends in THA in Europe and Experiences with Bicontact 209 different biomechanical concepts can lead to successful implant designs buy torsemide 20 mg without prescription, we use the favourable characteristics of the proximal bone preservation hip implant concept in our institution buy torsemide 20 mg visa. Not all current trends in hip arthroplasty are based on experience and sufficient clinical data buy torsemide 10 mg free shipping. Implantation for hip arthroplasties in younger patients should not lead us to an uncritical use of less-experienced methods and implants cheap torsemide 20mg with visa. However, innova- tion in medicine must also be studied with new technologies that seem to be promis- ing for the benefit of our patients. Wroblewski BM, Fleming PA, Siney PD (1999) Charnley low-frictional torque arthro- plasty of the hip. Bettin D, Greitemann B, Polster J, et al (1995) Long term results of uncemented Judet hip endoprostheses. Keisu KS, Mathiesen EB, Lindgren JU (2001) The uncemented fully textured Lord hip prosthesis: a 10- to 15-year followup study. Swanson TV (2005) The tapered press fit total hip arthroplasty: a European alternative. Weller S, Rupf G, Ungethum M, et al (1988) The Bicontact Hip System (in German). Malchau H, Garellick G, Eisler T, et al (2005) Presidential guest address. The Swedish Hip Registry: increasing the sensitivity by patient outcome data. Espehaug B, Furnes O, Havelin LI, et al (2006) Registration completeness in the Norwegian Arthroplasty Register. Eskelinen A, Remes V, Helenius I, et al (2006) Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid- to long-term follow-up study from the Finnish Arthroplasty Register. Pedersen AB, Johnsen SP, Overgaard S, et al (2006) Total hip arthroplasty in Denmark: incidence of primary operations and revisions during 1996–2002 and estimated future demands. Mittelmeier H, Heisel J (1992) Sixteen-years’ experience with ceramic hip prostheses. Willmann G (1998) Ceramics for total hip replacement: what a surgeon should know. Engh CA Jr, Young AM, Engh CA Sr, et al (2003) Clinical consequences of stress shielding after porous-coated total hip arthroplasty. D’Antonio JA, Capello WN, Manley MT, et al (2001) Hydroxyapatite femoral stems for total hip arthroplasty: 10- to 13-year followup. Kawamura H, Dunbar MJ, Murray P, et al (2001) The porous coated anatomic total hip replacement. A ten to fourteen-year follow-up study of a cementless total hip arthroplasty. Archibeck MJ, Berger RA, Jacobs JJ, et al (2001) Second-generation cementless total hip arthroplasty. Daniel J, Pynsent PB, McMinn DJ (2004) Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. Morrey BF, Adams RA, Kessler M (2000) A conservative femoral replacement for total hip arthroplasty. Kiefer H, Othman A (2005) Orthopilot total hip arthroplasty workflow and surgery. Weller S, Braun A, Gekeler J, et al (1998) The Bicontact hip implant system. Gruen TA, McNeice GM, Amstutz HC (1979) Modes of failure of cemented stem-type femoral components: a radiographic analysis of loosening. Asmuth T, Bachmann J, Eingartner C, et al (1998) Results with the cementless Bicon- tact stem: multicenter study of 553 cases. Weller S, Braun A, Gellrich JC, Gross U (1999) Importance of prosthesis design and surface structure for primary and secondary stability of uncemented hip joint pros- theses. Volkmann R, Eingartner C, Winter E, et al (1998) Mid term results in 500 titanium alloy straight femoral shaft prostheses—cemented and cementless technique. Eingartner C, Volkmann R, Winter E, et al (2000) Results of an uncemented straight femoral shaft prosthesis after 9 years of follow-up. Eingartner C, Volkmann R, Winter E, et al (2001) Results of a cemented titanium alloy straight femoral shaft prosthesis after 10 years of follow-up.

Adrenaline treating (epinephrine) is the drug currently recommended in the management of all forms of cardiac arrest best torsemide 10mg. Pending definitive placebo-controlled trials discount 10mg torsemide free shipping, the indications discount torsemide 10 mg line, dose buy torsemide 20mg mastercard, and time interval between doses of adrenaline Actions of catecholamines (epinephrine) have not changed. In practical terms, for non- ● Within the vascular smooth muscle of the peripheral VF/VT rhythms each “loop” of the algorithm (see Chapter 3) resistance vessels, both 1 and 2 receptors produce lasts three minutes and, therefore, adrenaline (epinephrine) is vasoconstriction given with every loop. For shockable rhythms the process of ● During hypoxic states it is thought that the 1 receptors rhythm assessment and the administration of three shocks become less potent and that 2 adrenergic receptors followed by one minute of CPR will take between two and contribute more towards maintaining vasomotor tone. This may explain the ineffectiveness of pure 1 agonists, whereas three minutes. Therefore, adrenaline (epinephrine) should be adrenaline (epinephrine) and noradrenaline given with each loop. Small case series and retrospective studies ● The 2 agonist activity seems to become increasingly of higher doses after human cardiac arrest have reported important as the duration of circulatory arrest progresses ● The agonist activity (which both drugs possess) seems to favourable outcomes. Clinical trials conducted in the early have a beneficial effect, at least partly by counteracting 1990s showed that the use of higher doses (usually 5mg) of 2-mediated coronary vasoconstriction adrenaline (epinephrine) (compared with the standard dose of ● Several clinical trials have compared different catecholamine- 1mg) was associated with a higher rate of return of spontaneous like drugs in the treatment of cardiac arrest but none has circulation. However, no substantial improvement in the rate of been shown to be more effective than adrenaline survival to hospital discharge was seen, and high-dose (epinephrine), which, therefore, remains the drug of choice adrenaline (epinephrine) is not recommended. Adrenaline (epinephrine) may also be used in patients with symptomatic bradycardia if both atropine and transcutaneous pacing (if available) fail to produce an adequate increase in Actions of adrenaline (epinephrine) heart rate. Animal studies, and the clinical ● Increased glycogenolysis increases oxygen requirements and evidence that exists, suggest that it may be particularly useful produces hypokalaemia, with an increased chance of arrhythmia when the duration of cardiac arrest is prolonged. In these ● To avoid the potentially detrimental effects, selective circumstances the vasoconstrictor response to adrenaline 1 agonists have been investigated but have been found (epinephrine) is attenuated in the presence of substantial to be ineffective in clinical use acidosis, whereas the response to vasopressin is unchanged. In another study, 200 patients with in-hospital ● The half-life of vasopressin is about 20 minutes, which is cardiac arrest (all rhythms) were given either vasopressin 40U considerably longer than that of adrenaline (epinephrine). In experimental animals in VF or with PEA vasopressin Forty members (39%) of the vasopressin group survived for increased coronary perfusion pressure, blood flow to vital one hour compared with 34 (35%) members of the adrenaline organs, and cerebral oxygen delivery (epinephrine) group (P 0. A European multicentre ● Unlike adrenaline (epinephrine), vasopressin does not increase myocardial oxygen consumption during CPR out-of-hospital study to determine the effect of vasopressin because it is devoid of agonist activity versus adrenaline (epinephrine) on short-term survival has ● After administration of vasopressin the receptors on vascular almost finished recruiting the planned 1500 patients. Not all experts agree with this decision and the Advanced Life Support Working Group of the European Resuscitation Council (ERC) has not included vasopressin in the ERC Guidelines 2000 for adult advanced life support. Inadequate data support the use of vasopressin in patients with asystole or pulseless electrical activity (PEA) or in infants On the basis of the evidence from animal and children. However, a considerable amount of evidence suggests that its use during cardiac arrest is ineffective and possibly harmful. Neither serum nor tissue calcium concentrations fall after cardiac arrest; bolus injections of a calcium salts increase intracellular calcium concentrations and may produce myocardial necrosis or uncontrolled myocardial contraction. Smooth muscle in peripheral arteries may also contract in the Sodium bicarbonate in cardiac arrest presence of high calcium concentrations and further reduce ● Bicarbonate exacerbates intracellular acidosis because the blood flow. The most effective treatment for this reduced aortic pressure and a consequential reduction in coronary perfusion condition (until spontaneous circulation can be restored) is chest compression to maintain the circulation and ventilation to provide oxygen and remove carbon dioxide. Sodium bicarbonate Much of the evidence about the use of sodium bicarbonate has come from animal work, and both positive and negative results have been reported; the applicability of these results to humans is questionable. No adequate prospective studies have been Alternatives to sodium bicarbonate performed to investigate the effect of sodium bicarbonate on ● These include tris hydroxymethyl aminomethane (THAM), the outcome of cardiac arrest in humans, and retrospective Carbicarb (equimolar combination of sodium bicarbonate studies have focused on patients with prolonged arrests in and sodium carbonate), and tribonate (a combination of whom resuscitation was unlikely to be successful. Advantages THAM, sodium acetate, sodium bicarbonate, and sodium have been reported in relation to a reduction in defibrillation phosphate) thresholds, higher rates of return of spontaneous circulation, ● Each has the advantage of producing little or no carbon dioxide, but studies have not shown consistent benefits over a reduced incidence of recurrent VF, and an increased rate of sodium bicarbonate hospital discharge. Benefit seems most probable when the dose 79 ABC of Resuscitation of bicarbonate is titrated to replenish the bicarbonate ion and D-aspartate (NMDA) receptor, which has a role in controlling given concurrently with adrenaline (epinephrine), the effect of calcium influx into the cell, has been studied, but which is enhanced by correction of the pH. Its action as a buffer depends on the excretion Free radicals of the carbon dioxide generated from the lungs, but this is Oxygen-derived free radicals have been implicated in the limited during cardiopulmonary arrest. During both sodium bicarbonate can be recommended, and correction of ischaemia and reperfusion the natural free radical scavengers acidosis should be based on determinations of pH and base are depleted. Arterial blood is not suitable for these measurements; radical scavengers (desferrioxamine, superoxide dismutase, and central venous blood samples better reflect tissue acidosis.

Part 2 DIAGNOSING YOUR MYSTERY MALADY Copyright © 2005 by Lynn Dannheisser and Jerry Rosenbaum buy 20mg torsemide with visa. Many mystery maladies are characterized by vague symptoms that could be associated with many different conditions cheap 10mg torsemide fast delivery. They are diagnosed by the absence of evidence of any other disease that could account for those symp- toms 10mg torsemide with visa. Some mystery maladies have not even been recognized until recently generic torsemide 20 mg with mastercard, and many more are yet to be named. For example, as we mentioned in Chapter 1, multiple sclerosis, once known as “faker’s disease,” was finally recognized because advances in medical technology (magnetic resonance imaging [MRI] of the brain and spine) finally allowed objective verification. The disorder described in the following case study was still relatively unknown at the time it occurred. Although recognized today as a legitimate ailment, it is still not always easily identifiable by most physicians, and there remains disagreement among board-certified rheumatologists about its cause. Yet if left untreated, this condition can become chronic and debili- tating. Ellen, the woman in the following case study, and I (Lynn) were friends. So when she told me about her symptoms, I shared the Eight Step method with her. Until that time, apart from her inability to shed some unwanted pounds from her preg- nancy, she had been in excellent health. Thinking perhaps her weight was causing her symptoms, she began working out at a neighborhood fitness center three mornings a week. After a few days of vigorous exercise, her condition improved some- what but babysitting problems made it difficult for her to keep a steady workout schedule. And since her thirteen-month-old daughter was still not sleeping through the night, Ellen was often too tired to go to the gym. It seemed that taking naps to get herself through the day was a better use of her time. Ellen started feeling guilty about not getting more accomplished dur- ing the course of a day. She considered herself luckier than many; she had a helpful husband, a housekeeper who cleaned once a week, and a mother- in-law who always seemed available to babysit for the kids. She just couldn’t get herself motivated to do things outside the house because of her pain, soreness, and fatigue. When her daughter’s ability to sleep through the night improved, Ellen hoped that at least her chronic fatigue would diminish. But it didn’t, because now if she wasn’t getting up at night for the baby, she was getting up to uri- nate frequently. Soon her aches and pains became so bad that it hurt when her husband tried to hold her. Her condition had deteriorated to the point that her mother-in-law became a fixture in her home. Ellen kept insisting it was probably “just a flu” and refused to see a physician. Ellen shared her assumption with the family physician, and he agreed it sounded viral. Nevertheless, he ordered blood tests on the off chance that something else was going on. In the meantime, he told her to get extra rest and drink plenty of fluids. She followed his instructions, but staying in bed didn’t seem to offer any relief.

Remember the LIGHT principles buy torsemide 20 mg on line, and try to Life and plastic models—Anatomy teaching in small groups or for self put concepts purchase torsemide 10mg online, not an essay generic torsemide 20mg with visa, on the board discount torsemide 10 mg amex. Make sure that directed learning everyone has finished copying information before you rub the Computer assisted learning packages—Small groups with a tutor; large board clean. Using different colours can add emphasis and groups in computer laboratories; self directed learning Skills centres and simulators—Small groups learning clinical skills highlight your important messages. Photocopies of handwritten notes (and frequently photocopied elderly pages) look scrappy and tend not to be valued. Give Leave spaces in the handout for your learners to record the results of interactive parts of your talk—this ensures handouts to the learners at the beginning of the talk as copying that the handout the learners take away has more value down information is not a good use of their limited “face to than the one they were given. Use headings and diagrams to make the handouts exercises to be completed later, thus linking self directed intelligible. It is a good backup resource, and for critical presentations it is comforting to know that, if all else fails, you have transparencies in your bag. Presentations using an overhead projector have the advantage that they allow you to face your audience while pointing out features on the transparency. Ensure that the transparencies will fit the projector—most will display A4 size, but some are smaller, so check in advance. The absolute minimum height for text on transparencies is 5 mm, although using larger text and fewer words usually produces a more effective educational tool. Several simple transparencies are usually better than one complicated one. It is fairly straightforward to design your transparency on a computer then print it using a colour printer. Avoid using yellow, orange, and red, as these colours are difficult to see. You can write and draw directly on to the transparencies with felt tipped pens. Use permanent markers to avoid smudging, and place a sheet of ruled paper underneath so that the writing is evenly spaced. You can also use a photocopier to copy print on to a transparency, but remember that you may need to enlarge it to Paper copies of transparencies and slides make the text readable. One commonly used presentation method is to store transparencies in clear plastic sleeves that can be filed in a ring binder. When showing transparencies, do not overuse the technique of covering the transparency and revealing a little at a time—many learners find this irritating. Making your own slides can be difficult, so get help from the local illustration department or 47 ABC of Learning and Teaching in Medicine a commercial company. Ensure that the text is large enough to see when projected and that the slides are marked so that they are loaded in the projector correctly. Dual projection is rarely done well and rarely necessary unless you are using visual images (for example, x ray films, clinical photographs) with accompanying text. If you use dual projection make sure that each of the slides is labelled for the correct projector. Computer generated slides The ability to make computer generated slides (for example, PowerPoint) has transformed the way that many people create teaching materials and has greatly reduced the use of 35 mm slides. Try not to get seduced by the technology, however, and remember that it is just another educational tool. Having tried all of the colours and slide layouts available, many experienced lecturers now prefer simple formats that are easy to read and in which the medium does not get in the way of the message. However, the computer package has many useful tools—diagrams and “clip art” can help to conceptualise difficult problems. Video clips can be inserted into a presentation, but be certain that they are there to illustrate a point and not simply to show off your own technological skills. Use advanced formats for PowerPoint presentations only if you are well practised and Ground rules for slide preparation (35 mm or PowerPoint) comfortable with the medium. Ensure that the computer you are planning to use is x Use a clear font that is easily readable x Use a type size of 20 points or greater compatible with the multimedia projector.

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