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Hyporeflexia is an accompaniment of hemiballismus discount 25 mg nizagara with amex erectile dysfunction exercise, and may also be noted in brainstem encephalitis (Bickerstaff’s encephalitis) trusted 50mg nizagara erectile dysfunction cream, in which the presence of a peripheral nerve disorder is debated. Hyporeflexia is not a feature of myasthenia gravis but may occur in Lambert-Eaton myasthenic syndrome (cf. Cross References Age-related signs; Areflexia; Facilitation; Lower motor neurone (LMN) syndrome; Reflexes Hyposexuality Hyposexuality is a lack of sexual drive, interest, or activity. It may be associated with many diseases, physical or psychiatric, and/or medica- tions which affect the central nervous system. Along with hyper- - 166 - Hypotropia H graphia and hyperreligiosity, hyposexuality is one of the defining fea- tures of the Geschwind syndrome. Transactions of the American Neurological Association 1980; 105: 193-195 Cross References Hypergraphia; Hyperreligiosity Hypothermia Hypothalamic damage, particularly in the posterior region, can lead to hypothermia (cf. There are many pathological causes, including tumor, trauma, infarct, hemorrhage, sarcoidosis, Wernicke’s encephalopathy, fat embolism, histiocytosis X, and multiple sclerosis (rare) A rare syndrome of paroxysmal or periodic hypothermia has been described, and labeled as diencephalic epilepsy. Nonneurological causes of hypothermia are more common, including hypothyroidism, hypopituitarism, hypoglycemia, and drug overdose. BMJ 1973; 2: 696-697 Cross References Hyperthermia Hypotonia, Hypotonus Hypotonia (hypotonus) is a diminution or loss of normal muscular tone, causing floppiness of the limbs. This is particularly associated with peripheral nerve or muscle pathology, as well as lesions of the cerebellum and certain basal ganglia disorders, such as hemiballismus- hemichorea. Weakness preventing voluntary activity rather than a reduction in stretch reflex activity appears to be the mechanism of hypotonia. Brain 1986; 109: 1169-1178 Cross References Ataxia; Flaccidity; Hemiballismus; Hypertonia Hypotropia Hypotropia is a variety of heterotropia in which there is manifest downward vertical deviation of the visual axis of one eye. Using the cover test, this manifests as upward movement of the uncovered eye. Depending on the affected eye, this finding is often described as a “left- over-right” or “right-over-left. Improvement of ptosis is said to be specific for myas- thenia gravis: cold improves transmission at the neuromuscular junction (myasthenic patients often improve in cold as opposed to hot weather). A pooled analysis of several studies gave a test sensitivity of 89% and specificity of 100% with correspondingly high positive and negative likelihood ratios. Whether the ice pack test is also applicable to myasthenic diplopia has yet to be determined. International Journal of Clinical Practice 2004; 58: 887-888 Larner AJ, Thomas DJ. Postgraduate Medical Journal 2000; 76: 162-163 Cross References Diplopia; Fatigue; Ptosis Ideational Apraxia - see APRAXIA Ideomotor Apraxia (IMA) - see APRAXIA Illusion An illusion is a misinterpretation of a perception (cf. Illusions occur in normal people when they are tired, inat- tentive, in conditions of poor illumination, or if there is sensory impairment. They also occur in disease states, such as delirium, and psychiatric disorders (affective disorders, schizophrenia). Examples of phenomena which may be labeled illusory include: Visual: metamorphopsia, palinopsia, polyopia, telopsia, Pulfrich phenomenon, visual alloesthesia Auditory: palinacusis Vestibular: vertigo References Tekin S, Cummings JL. Oxford: OUP, 2003: 479-494 - 168 - Impersistence I Cross References Delirium; Delusion; Hallucination Imitation Behavior Imitation behavior is the reproduction by the patient of gestures (echopraxia) and/or utterances (echolalia) made by the examiner in front of the patient; these “echophenomena” are made by the patient without preliminary instructions to do so. They are consistent and have a compulsive quality to them, perhaps triggered by the equivo- cal nature of the situation. There may be accompanying primitive reflexes, particularly the grasp reflex, and sometimes utilization behavior. Imitation behavior occurs with frontal lobe damage; originally mediobasal disease was thought the anatomical correlate, but more recent studies suggest upper medial and lateral frontal cortex. Certainly imitation behavior never occurs with retrorolandic cortical lesions. A distinction has been drawn between “naïve” imitation behavior, which ceases after a direct instruction from the examiner not to imi- tate his/her gestures, which may be seen in some normal individuals; and “obstinate” imitation behavior which continues despite an instruction to stop; the latter is said to be exclusive to frontotemporal dementia. Journal of Neurology, Neurosurgery and Psychiatry 1996; 61: 396-400 Lhermitte F, Pillon B, Serdaru M. Part I: imitation and utilization behavior: a neuropsychological study of 75 patients. Obstinate imitation behavior in differentiation of frontotemporal dementia from Alzheimer’s disease. Lancet 1998; 352: 623-624 Cross References Echolalia; Echopraxia; Grasp reflex; Utilization behavior Imitation Synkinesis - see MIRROR MOVEMENTS Impersistence Impersistence is an inability to sustain simple motor acts, such as con- jugate gaze, eye closure, protrusion of the tongue, or keeping the mouth open. It is most commonly seen with lesions affecting the right hemisphere, especially central and frontal mesial regions, and may occur in association with left hemiplegia, neglect, anosognosia, hemi- anopia, and sensory loss.

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The result of 30 years’ clinical and experimental investigation The Growth of Bone was in 1912 published in a book 25mg nizagara fast delivery erectile dysfunction young male, The Growth of Bone: Observations in Osteogenesis purchase nizagara 25 mg free shipping sleeping pills erectile dysfunction. This was Macewen, by his extended researches in the phys- followed in 1921 by another work, The Growth iology of bone, greatly advanced our knowledge and Shedding of the Antlers of the Deer. He proved that bone was a living casting of the antlers in early spring followed by tissue capable of transplantation; he believed the the growth of a new pair provided him with the graft played a vital part during the process of opportunity of closely studying rapid massive incorporation. They provided a greater surface Royal Infirmary and saw the effect of the appli- than the massive graft, each forming a center of cation of antiseptic principles in the treatment of ossification that threw out osteoblasts from its compound fractures, the impressive lowered mor- whole periphery. Herein he displays a remarkable tality and the hastened healing of wounds. From insight, for this seems to provide an explanation that time onwards he became an ardent supporter of the quickened osteogenetic power of small of Lister, employing in his practice antiseptic medullary bone grafts, which have found such lotions and the carbolic spray for several years. But by the middle 1880s he was already using 211 Who’s Who in Orthopedics instruments forged from a single piece of steel Surgeon-General in Scotland, serving in the Navy and was boiling his gauze. In addi- installed in the hospital a steam sterilizer for tion to the onerous duties of this post, he threw dressings after the Schimmelbusch pattern; was himself with great energy into organizing the boiling his instruments in a fish kettle, wearing a Princess Louise Hospital for Limbless Soldiers gown and had discarded the spray. He adopted an and Sailors at Erskine, the counterpart in Scotland aseptic technique. In 1922 he was elected President great deal with catgut and at last succeeded in of the British Medical Association on its visit to making a completely reliable and absorbable Glasgow in that year. In 1923 he was elected Pres- suture material, which he continued to make to ident of the International Society of Surgeons and the end of his life. In 1879 he when he went out to the Australasian Medical operated upon a patient for the relief of subdural Congress at Melbourne. He received the honor of hemorrhage with hemiplegia and the same year Knighthood in 1902, was made a Companion of removed a brain tumor in a girl 14 years of age. He died of pneu- advance was his recognition that middle-ear monia on March 22, 1924. Mary Watson, daughter of Hugh Allan of This induced him to design and perfect an opera- Crosshill, Glasgow, and had three sons and three tion for mastoid disease. This work was personality was forceful; he was possessed of acclaimed all over the world and became a immense energy and driving power, prosecuting classic. The same year he published another work, his work as a scientific surgeon with consuming Atlas on Head Sections, in the fine production of zeal. His individualism and temperament pre- which he spared neither labor nor expense. He was tall, had experience in dealing with penetrating wounds of a commanding figure and was gifted with a clear, the thorax before he attempted a direct attack on resonant voice, all of which enabled him to hold the lungs. In 1895 he was asked to see a patient and often sway any audience he addressed. He who was desperately ill, emaciated and toxic from was born at a fortunate hour and took full advan- extensive active tuberculous disease of the left tage of the opportunities that were presented, lung with secondary pyogenic infection and turning all his talents to such development of abscess formation. The man recov- Macewen’s contributions were so varied and of ered his health completely and afterwards was such a quality that he must be regarded as one of actively engaged in earning his livelihood for the greatest surgeons of all time. In 1892 Macewen became Regius Professor of Surgery at Glasgow University, a post that entailed a good deal of teaching and transference of his surgical work to the Western Infirmary. He was also elected an Honorary Fellow of the Royal Colleges of Surgeons of England and of Ireland; several universities conferred honorary degrees upon him, and he received recognition from leading surgical societies abroad. Soon after the outbreak of war in 1914, he was commissioned as 212 Who’s Who in Orthopedics famous contributions are probably his studies on the pathogenesis of low-back pain, which led to a greater understanding of what many had pre- viously diagnosed as lumbago. He also had expertise in the areas of hallux rigidus, patellar dislocation, opponens transfer, whiplash injuries, pathological changes in the neurocentral joints of the cervical spine, lesions of the menisci, anterior tibial compartment syndrome, the effect on osteo- genesis of alternating currents in bone, blood supply of the vertebral bodies and the femoral head, the reaction of body tissues to ceramics, the microcirculation of the rotator cuff, and shoulder arthroplasty. He was awarded the Hunterian Lectureship of the Royal College of Surgeons of England for his studies on the rotator cuff. To North Ian MACNAB Americans, his knowledge and expertise, com- bined with his command of the English language 1921–1992 and his Churchillian oratory, made him one of the most sought-after orthopedic lecturers and visit- Ian Macnab was the son of a Scottish shipbuilder ing professors. When Ian was 5 years was exemplified in his classic Presidential old, his parents sent him home to Britain to Address, entitled “Seek and Ye Shall Find,” to the receive an education in an English boarding Canadian Orthopedic Association in 1977, in school. He attended medical school at the Uni- which he stated: “You do not have to be a trained versity of Birmingham, graduating with first-class investigator to discover. After a residency in general and orthope- serve your sense of wonder, your ability to be dic surgery, he served in the Royal Army Medical astonished and you must be sure that your brain Corps, from 1945 to 1947. He then completed remains connected to your retina so that you will his orthopedic training at the Royal National not only see, but you will also perceive.... More became interested in low-back disability and, at importantly, it is an attitude of mind.

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The screws stabilize the shell generic nizagara 50mg elite custom erectile dysfunction pump, while at the same time stabilizing the enlarged portion (see Figs buy nizagara 100mg low price erectile dysfunction herbal treatment options. Case Reports Patient 1 A 60-year-old woman with a bilateral hip dislocation, Crowe group IV, is shown in Fig. The CT scan shows a narrow true acetabulum but a normal medullary canal of the femur on both sides (Fig. After enlargement of the true acetabulum, the metal shell was implanted in the first stage of the operation (Fig. The right leg was pulled down by skeletal traction while the patient was con- scious. For the left side, the same two-stage procedure was performed, and the total hip arthroplasty was successfully finished (Fig. Preoperative CT find- ings: narrow true acetabulum and normal medullary canal of the femur THA for High Congenital Hip Dislocation 227 A Fig. D Second stage of operation Figure 10 show the findings at 1 month (A) and at 15 years (B) after surgery. The patient is now 75 years old, and X-ray findings show slight wear of the HDP cup component on the left side, which indicates the process should be carefully followed up. Patient 2 A 50-year-old woman with Crowe group III dysplasia of the right hip is shown in Fig. After the enlargement of the true acetabulum, the patient received a 228 M. X-ray findings at 1 month (A) and 15 years post- operative (B) A B bipolar-type prosthesis, which showed central migration over a short period (Fig. The bipolar prosthesis was revised and converted to a total hip prosthesis. Thirteen years after the conversion to total prosthesis, the hip is in good condition (Fig. In this case, the total hip prosthesis would have been a better choice than the bipolar prosthesis at the first surgery. Bipolar prosthesis shows central migration in a short period after surgery. Enlargement of the medullary canal of the femur In the second technique, to treat the slender femur, enlargement of the medullary canal (Fig. After femoral osteotomy at the base of the neck, multiple drill holes are made in the femur shaft in the anteroposterior direction 5mm apart for 25cm distally. A longitudinal osteotomy is made with an osteotome to split the femur along these holes. A rasp is used to enlarge the medullary canal to fit the selected stem size. After implantation of the prosthesis stem, four or five cerclage wires are wound around the femoral bone to stabilize the osteotomized portion (Fig. Patient 3 A 57-year-old woman with left unilateral high hip dislocation, Crowe group IV, is shown in Fig. In the CT scan, the upwardly displaced, slender femur and the narrow true acetabulum can be confirmed (Fig. In the first stage of the operation, enlargement of the true acetabulum and implantation of the metal shell were performed (Fig. X-ray findings at 57 years of age, preoperative (A), and at 72 years of age, 15 years postoperative (B) After the first stage of the operation was completed, the leg was pulled distally and the adjusting down of the femur was accomplished (Fig. In the second stage of the procedure, enlargement of the femoral medullary canal and implanting of the stem prosthesis were performed. After stabilizing the enlarged femur by cerclage wire, the femoral head was reduced and arthroplasty was completed (Fig. CT findings (arrows): upward displaced slender femur (A) and small acetabu- lum (B) A B A C D E Fig. Progression of the procedure: preoperative (A); first stage of operation (B); adjusting the femur downward by traction (C); second stage of operation (D); and 10 years after surgery (E) THA for High Congenital Hip Dislocation 233 Materials Since 1987 we have treated 36 cases, 45 joints, with the above-described technique (Tables 1, 2). Of 25 unilateral cases, 16 of the contralateral hips were in a low dislocation, Crowe group I or II, and 9 hips were normal. Except for the two bipolar-type prosthetic joints, 43 joints of the cementless-type prosthesis with multiholed metal cup and straight stem were implanted. One-stage operations were done in 18 joints and two-stage operations were done in 27 joints. Enlargement of the acetabular side was done in 45 joints and of the femoral side in 4 joints. The size of acetabular component used was from 50 to 54mm outside diameter.

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These spindle fibers attach to the chromosomes greatly enhances the ability of the zygote (produced at fertil- during metaphase I as the tetrads line up along the middle or ization from the unification of the mature ovum with a sper- equator of the cell discount nizagara 100 mg online erectile dysfunction psychological causes treatment. A spindle fiber from one pole attaches to matozoa) to undergo rapid cell division buy 100 mg nizagara erectile dysfunction kegel. Anaphase I is characterized by the separa- a topic of much scientific research. Cell division is stimulated tion of the homologues, as chromosomes are drawn to the by certain kinds of chemical compounds. The sister chromatids are still intact, but the cytokines are secreted by some cells to stimulate others to homologous chromosomes are pulled apart at the chiasmata. Contact with adjacent cells can also con- Telophase I begins as the chromosomes reach the poles and a trol cell division. The phenomenon of contact inhibition is a nuclear membrane forms around each set. Cytokinesis occurs as the cytoplasm and organelles are divided in half and the one process where the physical contact between neighboring cells parent cell is split into two new daughter cells. When contact is inter- cell is now haploid (n), meaning it has half the number of rupted, however, cell division is stimulated to close the gap chromosomes of the original parent cell (which is diploid-2n). Cell division is a major mechanism by which These chromosomes in the daughter cells still exist as sister organisms grow, tissues and organs maintain themselves, and chromatids, but there is only one chromosome from each orig- wound healing occurs. The cell The phases of meiosis II are similar to those of meiosis cycle is highly regulated by several enzymes, proteins, and I, but there are some important differences. The time between cytokines in each of its phases, in order to ensure that the the two nuclear divisions (interphase II) lacks replication of resulting daughter cells receive the appropriate amount of DNA (as in interphase I). As the two daughter cells produced genetic information originally present in the parental cell. In in meiosis I enter meiosis II, their chromosomes are in the the case of somatic cells, each of the two daughter cells must form of sister chromatids. No crossing over occurs in prophase contain an exact copy of the original genome present in the II because there are no homologues to synapse. Cell cycle controls also regulate when and to metaphase II, the spindle fibers from the opposite poles attach what extent the cells of a given tissue must proliferate, in order to the sister chromatids (instead of the homologues as before). Therefore, when one or more of the centromeres separate, the two single chromosomes are such controls are lost or inhibited, abnormal overgrowth will drawn to the opposite poles. The end result of meiosis II is that occur and may lead to impairment of function and disease. The distribution of chromatids during meio- Cell cycle (eukaryotic), genetic regulation of; Cell cycle sis is a matter of chance, which results in the concept of the (prokaryotic), genetic regulation of; Chromosomes, eukary- law of independent assortment in genetics. These enzymes interact with one another and molecular genetics 105 Cell cycle (eukaryotic), genetic regulation of WORLD OF MICROBIOLOGY AND IMMUNOLOGY CELL CYCLE (EUKARYOTIC), GENETIC molecules that promote the cell cycle) as pro-mitotic signals. For example, thy- REGULATIONCell cycle (eukaryotic), genetic regulation of OF rotrophic hormone, one of the hormones produced by the pitu- itary gland, induces the proliferation of thyroid gland’s cells. Estrogens are hormones eukaryotes, cell division may take two different paths, in that do not occupy a membrane receptor, but instead, penetrate accordance with the cell type involved. Mitosis is a cellular the cell and the nucleus, binding directly to specific sites in the division resulting in two identical nuclei is performed by DNA, thus inducing the cell cycle. The process of meiosis results in four nuclei, Anti-mitotic signals may have several different origins, each containing half of the original number of chromosomes. Both prokaryotes and eukaryotes undergo a final growth factor beta), which inhibits abnormal cell proliferation, process, known as cytoplasmatic division, which divides the proteins p53, p16, p21, APC, pRb, etc. The series of stages that a cell undergoes while pro- Oncogenes, until recently also known as proto-oncogenes, gressing to division is known as cell cycle. Cells undergoing synthesize proteins that enhance the stimuli started by growth division are also termed competent cells. When a cell is not factors, amplifying the mitotic signal to the nucleus, and/or progressing to mitosis, it remains in phase G0 (“G” zero). When each phase of the cell cycle is completed, the pro- interphase and mitosis. Interphase includes the phases (or teins involved in that phase are degraded, so that once the next stages) G1, S and G2 whereas mitosis is subdivided into phase starts, the cell is unable to go back to the previous one. Next to the end of phase G1, the cycle is paused by tumor sup- The cell cycle starts in G1, with the active synthesis of pressor gene products, to allow verification and repair of RNA and proteins, which are necessary for young cells to grow DNA damage. The time G1 lasts, varies greatly among eukary- genes stimulate other intra-cellular pathways that induce the otic cells of different species and from one tissue to another in cell into suicide or apoptosis (also known as programmed cell the same organism. To the end of phase G2, before the transition to mito- tion, such as mucosa and endometrial epithelia, have shorter sis, the cycle is paused again for a new verification and “deci- G1 periods than those tissues that do not require frequent ren- sion”: either mitosis or apoptosis. Along each pro-mitotic and anti-mitotic intra-cellular sig- The cell cycle is highly regulated by several enzymes, naling pathway, as well as along the apoptotic pathways, several proteins, and cytokines in each of its phases, in order to ensure gene products (proteins and enzymes) are involved in an that the resulting daughter cells receive the appropriate amount orderly sequence of activation and inactivation, forming com- of genetic information originally present in the parental cell. In plex webs of signal transmission and signal amplification to the the case of somatic cells, each of the two daughter cells must nucleus.

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This type of research is pop- ular in areas such as organisational management purchase 25 mg nizagara visa erectile dysfunction new treatments, com- munity development cheap nizagara 25mg with amex erectile dysfunction natural remedies, education and agriculture. Action research begins with a process of communica- tion and agreement between people who want to change something together. Obviously, not all people within an organisation will be willing to become co-researchers, so action research tends to take place with a small group of dedicated people who are open to new ideas and willing to step back and reflect on these ideas. The group then moves through four stages of planning, acting, observing and reflecting. This process may hap- pen several times before everyone is happy that the changes have been implemented in the best possible way. In action research various types of research meth- od may be used, for example: the diagnosing and eval- uating stage questionnaires, interviews and focus groups may be used to gauge opinion on the proposed changes. Ethnography Ethnography has its roots in anthropology and was a popular form of inquiry at the turn of the century when anthropologists travelled the world in search of remote tribes. The emphasis in ethnography is on describing and interpreting cultural behaviour. Ethnographers im- merse themselves in the lives and culture of the group being studied, often living with that group for months on end. These researchers participate in a groups’ activ- ities whilst observing its behaviour, taking notes, con- ducting interviews, analysing, reflecting and writing 18 / PRACTICAL RESEARCH METHODS reports – this may be called fieldwork or participant ob- servation. Ethnographers highlight the importance of the written text because this is how they portray the cul- ture they are studying. Feminist research There is some argument about whether feminist inquiry should be considered a methodology or epistemology, but in my opinion it can be both. Epistemology, on the other hand, is the study of the nature of knowledge and justification. Often, in the past, research was conducted on male ‘subjects’ and the results generalised to the whole popu- lation. Feminist researchers critique both the research topics and the methods used; especially those which em- phasise objective, scientific ‘truth’. With its emphasis on participative, qualitative inquiry, feminist research has provided a valuable alternative framework for research- ers who have felt uncomfortable with treating people as research ‘objects’. Under the umbrella of feminist re- search are various different standpoints – these are dis- cussed in considerable depth in some of the texts listed at the end of this chapter. Grounded theory Grounded theory is a methodology which was first laid out in 1967 by two researchers named Glaser and HOW TO DECIDE UPON A METHODOLOGY / 19 Strauss. It tends to be a popular form of inquiry in the areas of education and health research. The emphasis in this methodology is on the generation of theory which is grounded in the data – this means that it has emerged from the data. This is different from other types of re- search which might seek to test a hypothesis that has been formulated by the researcher. In grounded theory, methods such as focus groups and interviews tend to be the preferred data collection method, along with a com- prehensive literature review which takes place through- out the data collection process. In grounded theory studies the number of people to be interviewed is not specified at the beginning of the re- search. This is because the researcher, at the outset, is unsure of where the research will take her. Instead, she continues with the data collection until ‘saturation’ point is reached, that is, no new information is being provided. Grounded theory is therefore flexible and en- ables new issues to emerge that the researcher may not have thought about previously. Perhaps the easiest way to do this is to de- cide first of all whether you should consider qualitative or quantitative research. If you have not already done so, go through each question in relation to your own research. Once you have done this, clues will start to emerge about what is the best form of inquiry for you. Cer- tain words help to suggest a leaning towards qualitative research, others towards quantitative research. For exam- ple, if you have written ‘how many’, ‘test’, ‘verify’, ‘how often’ or ‘how satisfied’, this suggests a leaning towards quantitative research. If you have written words such as ‘discover’, ‘motivation’, ‘experiences’, ‘think/thoughts’, ‘problems’, or ‘behave/behaviour’, this suggests a leaning towards qualitative research. However, you may find that you have written a combination of these words which could mean two things.

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