Howard Mark Lederman, M.D., Ph.D.

• Director, Immunodeficiency Clinic
• Professor of Pediatrics

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0000112/howard-lederman

It should become readily apparent that the etiology of dizziness may involve in the inner ear low cholesterol food indian purchase cheapest atorlip-10 and atorlip-10, the central nervous system or a systemic disorder cholesterol levels of seafood discount atorlip-10 10mg amex. Subjective: Symptoms Focused History: Does the patient have a prior history that can account for recurrent dizziness such as Meniere’s disease or vertigo? Chronic symptoms suggest either anatomic abnormalities cholesterol levels vegetarian diet safe atorlip-10 10 mg, such as acoustic neuroma cholesterol medication for dogs order 10 mg atorlip-10 visa, or chronic illness such as Meniere’s) Illness Has the patient been ill cholesterol lowering medication options generic atorlip-10 10 mg, especially any upper respiratory illnesses? Neurologic: Dix-Hallpike Maneuver* positive symptom reproduction and rotatory nystagmus – vertigo cholesterol test without fasting purchase atorlip-10 once a day. Instruct the patient to keep their eyes open and to stare at the examiner’s nose during the test. Keeping the head in this position, lie the patient down rapidly until the head is dependent and extended below the table. In each position, observe the eyes closely for up to 40 seconds for development of nystagmus. To test the right posterior canal, repeat maneuver with the head turned 45° to the right side. Assessment: Differential Diagnosis Meniere’s Disease a chronic disorder resulting in decreased hearing acuity over long duration, accompanied by multiple exacerbations of vertigo and tinnitus. If the patient has dizziness only when walking or standing, he does not have true vertigo. Change the angular displacement of the head by about 90° with each position change. Rapidly perform the changes in head positions and maintain each position until nystagmus has disappeared, indicating cessation of endolymph flow. If no nystagmus is visible, the latency and duration of nystagmus observed during Dix-Hallpike testing may serve as a guideline. Guide head movements from behind and execute each change in position within one second; maintain each position for at least 30 seconds. If vertigo is severe, pre-medicate patient with a vestibular sedative, such as prochlorperazine or dimenhydrinate, 30-60 minutes before performing the maneuver. Rotate the head so that it is facing obliquely downward, with nose 45° below horizontal. Simultaneously rotate the head to central position and move it 45° forward (return to normal position). Serous otitis media is probably secondary to eustachian tube dysfunction from allergy, barotrauma 3-21 3-22 or viral infection. Follow-Up: Return if dizziness persists beyond 7-10 days, or if symptoms worsen or if alteration of hearing is noted. Evacuation/Consultation Criteria: Evacuate patients with persistent or recurrent symptoms of vertigo or dizziness, especially if there is an alteration of hearing, for neurological evaluation. Vision loss in one eye due to giant cell arteritis is often rapidly followed by loss in the other eye if untreated. Subjective: Symptoms Sudden versus gradual loss of vision, eye pain, seeing bright spots, fever, headache, foreign-body sensation, increased sensitivity to light or photophobia (from irritation of cornea or iris), dry eye, jaw pain. Focused History: Quantity: Have you lost your central or peripheral vision or noticed a blind spot? Objective: Signs Partial or total loss of vision, fever, jaw tenderness, conjunctivitis, photophobia Using Basic Tools: Inspect extraocular muscles. Have patient look in all directions and note any limitations that may indicate entrapment of a muscle, orbital fracture or palsy. Color Vision: Red image less vivid in optic neuritis Snellen Chart (if available): Loss of visual acuity may be seen in any of the conditions. Optic neuritis central decrease in vision and a color vision deficit, peripheral neurologic signs. If supplemental oxygen is to be of any benefit a response is typically seen in a few minutes. Primitive: Hyperventilate to decrease the amount of retained carbon dioxide and increase available oxygen to tissues. Patient Education General: Patient has severe visual dysfunction and needs immediate care to have the best chance for vision recovery. Subjective: Symptoms Fever, eye pain, loss of vision, redness, discharge, foreign-body sensation (especially in chemical injuries), increased sensitivity to light or photophobia (irritation of cornea or iris), dry eye, nausea and vomiting (if the intraocular pressure rises suddenly). Objective: Signs Using Basic Tools: Vital signs: Fever may indicate systemic infection. Have patient look in all directions and note any limitations that may indicate entrapment of a muscle or palsy. Flashlight: Look for injected conjunctival vessels: perilimbal (cornea-sclera junction) injection indicates iritis; diffuse injection indicates infection or corneal disease. Look for discharge: Mucoid discharge may indicate viral infections, whereas purulent discharge may indicate bacterial infection Snellen Chart (if available): Decreased visual acuity to between 20/40 and 20/100. Decreased vision indicates abnormality in anterior segment (cornea, crystalline lens or iris). If a Snellen chart is not available, reading the print in a book or other printed material will provide a rough measure of visual acuity. Episcleritis benign and self-limited inflammation of the episclera (the lining of the eye between the conjunctiva and the sclera); identified by sectors of redness, no discharge and often a history of previous episodes; discomfort is typically mild or absent. Conjunctival foreign body identification of the foreign material Dry eye usually bilateral and may result in secondary tearing; history of previous episodes; occurs in dry environments. Contact lens overwear syndrome as in dry eye, except that the symptoms are magnified by the presence of contact lenses Subconjunctival hemorrhage bleeding often seen with coughing or retching; innocuous and self-limited Plan: Treatment Herpes simplex keratitis: Expedited evacuation; do not use steroids; patch eye. Scleritis or iritis: Prednisolone 1%, 1 drop q1 hour continuously until evacuated. Blepharitis: Bacitracin ophthalmic ointment applied to the lid margins q hs x 3-4 weeks; apply qid for 1 week in more severe cases; warm compresses for 10 minutes bid-qid. Ultraviolet Keratitis: Bacitracin ophthalmic ointment qid until signs and symptoms resolve; sunglasses; patch severely affected eyes for comfort; scopolamine 0. Episcleritis: Usually resolves without treatment over several weeks; use prednisolone 1% drops qid x 3 days if persistent and patch eye. Patient Education General: Discuss the level of injury with the patient but do not give prognosis in diseases that should be managed at a higher level of care. Activity: As tolerated Diet: As tolerated Prevention and Hygiene: Keep eyes clean. Contact lens wearers in the wilderness should always carry a pair of glasses that can be worn if contact lens problems arise. Subjective: Symptoms Periocular edema, erythema, pain, possibly sensing a foreign body in or near the orbit. Objective: Signs Using Basic Tools Clinical Findings Interpretations Vital signs Fever May be indicative of orbital cellulitis Printed material Check visual acuity* Corneal damage, discharge; dysfunction of some aspect of vision Flashlight Swollen eyelid(s); eye Indicates orbital or preseptal cellulitis slightly protruding from orbit when compared to opposite side Using Advanced Tools Clinical Findings Interpretations Ophthalmoscope Observe fundus for signs of May indicate advanced orbital disease retinal or optic nerve disease Fluorescein Strip Staining? Pearl: Check eye movements (decreased eye movements indicate orbital process) Assessment: Differential Diagnosis Preseptal cellulitis associated with a history of periocular trauma or hordeolum (stye), no proptosis (protrusion of the eye), no restriction or pain with eye movement and no change in visual acuity. Dacryocystitis a specific type of preseptal cellulitis in which the source of the infection is an obstructed nasolacrimal duct. The erythema and inflammation are localized to the area overlying the lacrimal sac at the inferior nasal aspect of the lower lid. Periocular insect envenomation may have a papular or vesicular lesion at the site of envenomation. Orbital cellulitis associated with a history of sinusitis or upper respiratory tract infection, proptosis (protrusion of the eye), restricted extraocular muscle motility, decreased visual acuity and/or fever. Preseptal cellulitis: levofloxacin 500 mg po once a day, expedite evacuation if no improvement in 24-48 hours. Periocular insect envenomation: cool compresses and antihistamines; levofloxacin 500 mg po once a day if secondary infection is suspected based on increasing pain, redness, or swelling. Orbital cellulitis: life-threatening disorder requiring emergent evacuation, levofloxacin 500 po mg bid and decongestants. Diet: Regular as tolerated Prevention: Good personal hygiene Wound Care: Warm or cool compresses, depending on diagnosis. Evacuation/Consultation Criteria: Immediate evacuation for acute proptosis and/or decreased eye motility. Assessment: Differential Diagnosis Hyphema blood seen in anterior chamber Orbital fracture detected by extra-ocular muscle derangement or new onset gaze derangement 3-27 3-28 Occult ruptured globe suspect with history of blunt or impaling injury, dark uveal tissue exposed at junction of cornea and sclera, a distorted pupil, or a decrease in vision Traumatic iritis pain and photophobia Subconjunctival hemorrhage bright red area of blood overlying the sclera Also consider corneal abrasion, corneal ulcer, foreign body, obvious ruptured globe, Plan: Treatment 1. Cover all injured eyes with a metal shield or other device to prevent further injury. Occult ruptured globe: An occult ruptured globe also entails the possibility of endophthalmitis. If an open globe is suspected, protect the eye until definitive treatment is obtained. Remove the patch daily to check for the development of a corneal ulcer and to repeat the fluorescein stain to monitor healing. Use topical ciprofloxacin or ofloxacin 1-2 drops qid until the abrasion is healed and watch the eye closely for development of a corneal ulcer. Corneal ulcer: topical ciprofloxacin or ofloxacin as follows: 1 drop every 5 minutes for 3 doses; 1 drop every 15 minutes for 6 hours; then 1 drop every 30 minutes. A corneal ulcer is a vision-threatening disorder that may progress rapidly despite therapy, so evacuate should emergently if pain and inflammation continue to increase or expedite evacuation even if the ulcer is responding to therapy. Subconjunctival hemorrhage requires no treatment, but carefully inspect the eye for associated injuries. If the subconjunctival hemorrhage is massive and causes outward bulging of the conjunctiva (called chemosis), then suspect an occult ruptured globe and manage as described above. Hyphema: the primary concerns in this disorder are associated globe rupture, increased pressure in the eye and permanent damage to vision. Rest in a foot-dependent position to encourage blood to settle in the bottom of the anterior chamber. If evacuation is delayed use prednisolone ophthalmic drops qid in the affected eye for 3 days. Severe cases may be treated with topical prednisolone 1% drops qid for three days if evacuation is not available and no lesion is noted on fluorescein exam. Lid Laceration: Any laceration that is full-thickness, involves the lid edge, or is in the medial or lateral corners (epicanthal folds) should be repaired by an ophthalmologist. Repair partial thickness lacerations that are not in the areas mentioned above with simple 6-0 proline sutures, sterile technique, and limited 2% lidocaine in the lid. Locate and remove foreign body using enhanced lighting and magnification if available. Evert upper eyelid with a cotton tipped applicator to identify foreign bodies there and remove them with a cotton-tipped applicator moistened with tetracaine. If symptoms persist, irrigate vigorously with artificial tears or sweep conjunctival corners with a moistened cotton-tipped applicator after applying topical anesthesia. Although topical steroids should not be given except by ophthalmologists, prednisolone drops will probably not cause any significant adverse effects in an individual with a fluorescein-negative eye disorder if used no longer than three days. Prevention and Hygiene: All eye patients should maintain a high level of hygiene while recovering from their injury. Follow-up Actions Return evaluation: Follow patients closely on daily basis for signs of improvement or worsening. Evacuation/Consultation Criteria: Evacuate patients as indicated in Treatment above and any patient who does not show improvement within 24-48 hours. Broadly assess body systems when taking a history because fatigue may be due to an underlying endocrine disorder, systemic illness, sleep disorder, drug side effect (recreational or prescribed), or psychiatric disorder. If the patient’s history does not yield a specific etiology, a careful psychiatric history for depression should be performed. Expect to find more psychiatric illness (usually depression) than organic disease if the patient has a primary complaint of fatigue rather than fatigue as part of a clustering of symptoms. Subjective: Symptoms Focused History: Sleeping: Have you had trouble with sleeping or had a change in your sleep pattern? Does the patient feel like their thoughts are slower than usual, or seem to be fleeting? Any time the diagnosis of depression is entertained, screen the patient for suicidal or homicidal ideation. Vital signs Vital signs Check pulse ox if available Hypoxemia may cause isolated fatigue rather than dyspnea. However, a routine set of basic labs should be drawn prior to initiation of treatment of depression or other psychiatric illness. Plan: Treatment Stopped Medication Resume medication or consider alternate if side effects are a problem. Altered sleep patterns Primary: Ambien (zolpidem) or Sonata (zaleplon) 5-10 mg po at bedtime Alternate: Antihistamines (more side effects) such as Benadryl or Atarax Melatonin helps restore abnormal circadian rhythms resulting from shift work or jet lag. Paxil or tri-cyclic antidepressants should be avoided as these often have the side effect of fatigue! Patient Education General: Symptom reduction help the patient to learn to cope with their symptoms and maintain their highest possible functioning level. This requires a good medic-patient alliance and a mutual understanding of the diagnosis and treatment goals. Follow-Up: Follow patient on a routine schedule to assess for improvement of symptoms with treatment interventions. Evacuation/Consultation Criteria: Acute evacuation is not usually necessary, unless the patient is unstable or non-mission capable. If labs remain unrevealing and the patient has persistent symptoms of fatigue for greater than 6 months, then a diagnosis of chronic fatigue may be entertained and the patient referred. Significant fever (oral temperature >101°F in an adult) is a common symptom of infectious disease, but it can be seen with other conditions such as malignancy, heat-related illness, drug reactions, rheumatologic conditions, or hyperthyroidism. Several principles apply to the initial approach of a febrile patient: · Assess first for infections that can be quickly life-threatening (the duration of fever, place and type of exposure, related clinical symptoms can be helpful in further directing you).

Although these criteria may be helpful in aiding the diagnosis of lupus definition of cholesterol in health discount atorlip-10 10 mg fast delivery, patients who do not fulfill the classification criteria may still have the disease cholesterol ratio hdl atorlip-10 10mg on line. Discrete erythematous plaques covered by scales that extend into hair follicles results of cholesterol test cheapest generic atorlip-10 uk, causing follicular plugging cholesterol what to eat buy cheap atorlip-10 10mg on line. Raynaud’s Bullae Livedo reticularis phenomenon Livedo reticularis Alopecia Periungual Petechiae telangiectasia Vasculitis 81 cholesterol in food levels buy atorlip-10 visa. List the differential diagnoses of a lupus patient who presents with musculoskeletal complaints cholesterol levels conversion order generic atorlip-10 on line. Synovitis Myopathy Septic arthritis Fibromyalgia Osteonecrosis Adrenal insufficiency Myositis Fractures Some of these disorders are related to the disease itself, whereas others may be related to medication side effects or existing comorbid conditions. Although there are reports of subsequent disease exacerbations, disease activity usually does not recur in transplanted kidneys. Oral ulcerations (most commonly painless buccal erosions) were identified in 40% of one group of patients. Esophageal involvement such as esophagitis, esophageal ulceration, or esophageal dysmotility seems to correlate with the presence of Raynaud’s phenomenon. Intestinal involvement results in abdominal pain, diarrhea, and occasionally, hemorrhage. Intestinal ischemia may be present and may progress to infarction and perforation. Vasculitis is suggested by such commonly used designations as “lupus cerebritis” and occurs in < 15% of patients. Neuropsychiatric manifestations of lupus may occur in approximately 70% of patients. The cause for this problem is not known, but cytokines are believed to play an important role. Leroux G, Sellam J, Costedoat-Chalumeau N, et al: Posterior reversible encephalopathy syndrome during systemic lupus erythematosus: Four new cases and review of the literature, Lupus 17:139–147, 2008. Effusions can be either transudative or exudative and, in rare cases, are the presenting feature. The so-called shrinking lung syndrome describes dyspnea associated with diaphragmatic dysfunction, probably secondary to chronic pleural scarring. Pulmonary parenchymal involvement or lupus pneumonitis has been described, as have pulmonary hemorrhage, pulmonary emboli, and pulmonary hypertension. The clinical features usually regress fairly promptly, although the laboratory abnormality may persist (sometimes indefinitely) when the drug is discontinued. There are numerous published reports of many other drugs inducing lupus symptoms on a small number of patients. Survival in those with late-onset disease seems to be reduced compared with survival among those patients afflicted at an earlier age. Of the causes of death not directly related to active disease, infection is most common, followed by myocardial infarction, stroke, and other atherosclerotic complications. Recent data suggest, though, that pregnant patients with lupus do not have disease flares more frequently than nonpregnant patients. Preeclampsia, premature births, spontaneous abortions, intrauterine growth delay, and intrauterine fetal deaths are higher in lupus patients. Active disease during the antecedent 3–6 months may increase the risk of flare during the pregnancy. Pregnancy outcome is optimal if the disease has been under control for at least 6–12 months. These antibodies can be specific (such as anticardiolipin antibodies), or they may be identified by their effect on the clotting cascade (lupus anticoagulant). A connective tissue disease is characterized by abnormal collagen deposition into the skin and other organs. The term “scleroderma” is derived from two Greek words: skleros, meaning hard, and derma, meaning skin. Disease pathogenesis is believed to occur as a consequence of aberrant immune activation causing endothelial damage, followed by fibroblast activation that results in obliterative vasculopathy and fibrosis. Calcinosis, Raynaud’s, esophageal dysmotility, sclerodactyly, and telangiectasias. This has been elegantly shown in a population study of Choctaw Indians, in whom a genetic defect has been traced to a single common ancestor. Antitopoisomerase 1 (anti–Scl-70) has a positive predictive value of 70% for developing scleroderma. Spencer-Green G: Tests preformed in systemic sclerosis: Anticentromere antibody and anti Scl-70 antibody, Am J Med 103:242–248, 1997. Angiotensin-converting enzyme inhibition therapy has been shown to improve clinical outcomes. Patients may have small oral aperture, dry mucosal membranes with periodontal disease, esophageal dysmotility, reflux, esophagitis, stricture, dysphagia, delayed stomach emptying, pseudo-obstruction of the small intestines, bacterial overgrowth, malabsorption, wide mouth diverticuli, and fecal incontinence due to rectal sphincter fibrosis. Scleredema is a dermatosis of unknown etiology characterized by symmetrical truncal skin induration and thickening, sometimes with erythema. A high proportion of cases are associated with diabetes, malignancies, and infections. Skin biopsy of a patient with scleredema may reveal thickened dermal collagen with a mild infiltration of mucin in the deeper regions of the dermis. Scleromyxedema (also called “papular mucinosis”) is characterized by raised pale, waxy papules that result from excessive mucin deposition distributed over the face, fingers, arms, and legs. For a definite diagnosis of polymyositis, four criteria must be present without the rash. Both polymyositis and dermatomyositis are characterized by muscle weakness and abnormal muscle findings, but the disorders differ significantly. Sclerotic thickening of the dermis, contractures, esophageal hypomotility, microangiopathy, and calcium deposits may be present in dermatomyositis but typically are not seen with polymyositis. A South American plant with clusters of rich purple flowers, whose scent is similar to cherry pie, named “heliotrope. Anti-Mi-2 is found in patients with classic dermatomyositis; these patients have good prognoses and will respond well to treatment. Specific clinical manifestations include myositis, interstitial lung disease, arthritis, Raynaud’s phenomenon, fever, and mechanics hands. What further evaluation for an occult malignancy should be undertaken in an adult diagnosed with dermatomyositis? Because of the increased risk of malignancy in patients with myositis, particularly dermatomyositis, age-appropriate cancer screening should be pursued. Other unifying features include peripheral oligoarthropathy, enthesopathy, and extra-articular foci of inflammation such as uveitis. Although the exact mechanism is unknown, one hypothesis suggests that B27 presents an arthritogenic peptide or alters immune repertoire through its antigen presentation role. Another possibility is that the B27 peptide itself may be prone to misfolding, forming homodimers that subsequently trigger an inflammatory response. In addition, we know that individuals who are homozygous for B27 are three times more likely to develop ankylosing spondylitis than heterozygotes, suggesting a gene dosage effect. Syndesmophytes represent ossification of the outer layers of the annulus fibrosus (Sharpey’s fibers), creating an osseous bridge across vertebra at the discovertebral junction. The syndesmophyte is a characteristic radiographic finding in ankylosing spondylitis, though it may be seen in any of the spondyloarthropathies. Spinal osteophytes are triangular ossifications, continuous with the vertebral bodies, forming at either the margins of a vertebral body or a few millimeters from the margin of the discovertebral junction. List the five patterns of joint involvement found in psoriatic arthritis and their relative frequencies. Nonpharmacologic treatment, including patient education and exercise programs, should also be part of the treatment approach. A varied group of disorders that share a common underlying pathology of inflammation of a single blood vessel or blood vessels. Vasculitis occurs as a primary disorder or secondary to a variety of diseases or drugs. By the predominant sizes of the involved blood vessels (large, medium, and small). An inflammatory condition that causes pain or stiffness, usually in the neck, shoulder girdle, and hip girdle with sudden onset and occurrence in patients older than 50 years. If the extracranial branches of the aorta (with sparing of the intracranial vessels) are involved, the classic manifestations of blindness, headache, scalp tenderness, and jaw claudication are seen. Involvement of the subclavian, axillary, and proximal brachial arteries leads to the aortic arch syndrome of claudication of the arms and absent or asymmetric pulses. The populations at highest risk include women who are adolescent or in the second and third decades of life. Clinical manifestations range from asymptomatic disease with nonpalpable pulses to catastrophic neurologic impairment (stroke, postural dizziness, seizures, and amaurosis). A vasculitis characterized by necrotizing inflammation of medium-sized or small arteries. Fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, rash, extremity changes, and lymphadenopathy. Respiratory tract involvement can manifest as recurrent sinusitis, otitis media, tracheobronchial inflammation and erosions, lung nodules, or pneumonitis with cavitation. The heart, skin, and kidneys may also be affected, and eosinophilia and severe asthma are very characteristic. By pauci-immune necrotizing small vessel vasculitis of the lungs and kidneys without clinical or pathologic evidence of necrotizing granulomatous inflammation. Small vessel vasculitis caused by the localization of mixed cryoglobulins in vessel walls, which incites acute inflammation. As a small vessel vasculitis characterized by vascular deposition of IgA-dominant immune complexes. Purpura, arthralgias, and colicky abdominal pain are the most frequent manifestations. Approximately half the patients have hematuria and proteinuria, but only 10–20% have renal insufficiency. A systemic vasculitic disorder of unknown etiology, characterized by relapsing episodes of oral aphthous ulcers, genital ulcers, skin lesions, and ocular lesions (retinal vasculitis, anterior and posterior uveitis). The treatment choices for vasculitis will be determined by the type and severity of the manifestations of the disease. Some commonly used immunosuppressants include cyclophosphamide, azathioprine, and methotrexate. Perhaps the most recognized inherited feature is the presence of Heberden’s nodes in mothers and sisters of affected patients. With cervical disease, patients typically present with pain and limitation of motion. In the lumbar region, the clinical manifestations are mostly those of neurogenic claudication and compression of the cauda equina when severe. Diffuse idiopathic skeletal hyperostosis characterized by extensive ossification of tendinous and ligamentous attachments to the bone. Spine involvement with flowing calcification over the anterior longitudinal ligament is among the most common findings. A radiographic finding seen in degeneration of the intervertebral disc that has the appearance of a radiolucent stripe in an intervertebral disc. Radiolucencies represent gas or nitrogen that appears at the site of negative pressure produced by abnormal spaces of clefts. Antibody formation to group A streptococcus that occurs after pharyngeal infection, which may be asymptomatic. Arthritis is one of the earliest manifestations of rheumatic fever and has a migratory pattern. A neurologic disorder consisting of abrupt, purposeless involuntary movements that disappear during sleep. The disorder is found in patients with rheumatic fever and is also called “Syndenham’s chorea” or “chorea minor. Polyarteritis nodosa, likely associated with persistent circulating hepatitis B antigen. Joint symptoms usually begin within 1 week of the onset of the rash of rubella and include arthralgia and arthritis, especially in adult women. In the past, arthritis and arthralgias often were seen after rubella vaccination, but they are less common because a less arthrogenic strain of virus is used for the vaccine. What are the clinical manifestations of Lyme disease and the time of their occurrence in the untreated disease course? Other skin manifestations include benign lymphocytoma and acrodermatitis chronica atrophicans. Why is the polarizing microscope important in the diagnosis of rheumatic diseases? To analyze synovial fluid and identify the specific etiologies of inflammatory arthritis, in particular crystal-induced arthritis. The microscopy operates on the relatively simple observation that some crystals refract light into fast and slow rays. Polarized light passing through a crystal is no longer parallel to light not passing through the crystal. If a second polarizer is added so that its axis is rotated 90 (extinction) to the light as it emerges from the first polarizer but after some light is bent (rotated) by the crystal in between the polarizers, the only light reaching the observer’s eye is the light that the crystal has rotated. Monosodium urate crystals have a strongly negative birefringent appearance on polarized light microscopy and appear yellow when oriented parallel to the axis of the compensator. Calcium pyrophosphate crystals are weakly positively birefringent and appear blue when oriented parallel to the axis of the compensator. The cartilages appear punctate or stippled with linear densities within the articular hyaline or fibrocartilage in knee menisci, radiocarpal joints, annulus fibrosus of intervertebral discs, and symphysis pubis. The prevalence in the general population (as assessed by multiple radiologic studies) is 10–15% in people aged 65–75 years but rises above 40% in people older than 80 years. Elevated serum urate levels in the absence of symptomatic articular disease or nephrolithiasis.

Cystine kidney stones (1% of all renal stones) are the major clinical manifestation cholesterol in poultry eggs order atorlip-10 10mg line, and they are radiopaque cholesterol levels lipid profile purchase atorlip-10 in united states online. Causes of magnesium deficiency also include milk diets in infants low cholesterol foods and recipes best atorlip-10 10 mg, the diuretic phase of acute tubular necrosis cholesterol medication guidelines 2015 cheap atorlip-10 online american express, chronic diuretic therapy cholesterol food chart nhs buy discount atorlip-10 online, acute pancreatitis cholesterol ranges healthy 10 mg atorlip-10 for sale, and inappropriate antidiuretic hormone. The symptoms of hypomagnesemia include anorexia, nausea, tremor, and mood alteration. It is an autosomaldominant disorder and different affected family members may display different dyslipidemic phenotypes. Familial hypercholesterolemia (1/500) and familial defective Apo B (1/1000) are also common. They most commonly involve the legs but can also involve the hands, arms, abdomen, and head. This in not a staphylococcal skin infection since it is not tender, indurated or warm to touch, and erythema nodosum is characterized by round, tender elevated lesions usually on the anterior shin. Allopurinol is particularly useful in the treatment of uric acid nephrolithiasis in gouty individuals. Even if the gouty individual has calcium oxalate stones, allopurinol may be helpful. Its secondary effects on calcium can result in hypocalcemic tetany or metastatic calcification. Anorexia, nausea, and vomiting are not usual clinical features of hypocalcemia or hyperphosphatemia. They may occur if the patient has advanced chronic kidney disease and associated uremia. For the majority of patients with hypocalcemia there are no associated tachyarrhythmias. Long, thin extremities; ectopia lentis; and aortic aneurysms are the classical triad. In the familial type 1 form, the defect is believed to be a deficiency of lipoprotein lipase activity. It is a rare autosomal recessive syndrome, and usually presents in childhood with typical eruptive xanthoma and abdominal pain secondary to acute pancreatitis. Secondary hyperchylomicronemia (diabetes, hypothyroidism, uremia) is a much more common syndrome. The disorder is common, and heterozygous familial hypercholesterolemia is felt to affect 1 in 500 individuals. It can be secondary to other diseases such as hypothyroidism, nephrotic syndrome, or even porphyria. Xanthelasmas after the age of 50 are often not related to any dyslipidemia at all. Dietary therapy and the maintenance of ideal weight is the cornerstone of therapy. It can be a normal response to caloric excess or alcohol ingestion and is common in the third trimester of pregnancy. Psychogenic polydipsia is commonly seen in patients with psychiatric problems on medications. Hypothyroidism, renal disease, alcoholism, and anorexia nervosa are also associated with secondary dyslipidemias. Many drugs (eg, estrogen, glucocorticoids) can also cause secondary dyslipidemias. The bony lesions are osteoblastic, and the sacrum and pelvis are most frequently involved, followed closely by the tibia and femur. Hypercalcemia is not usually a feature of Paget, though can occur as a complication of immobilization. In metastatic cancers of most types the lesion are lytic, and the other metabolic abnormalities listed do not have an elevation in hydroxyproline. Decreased calcium absorption, which is vitamin D dependent, results in mild hypocalcemia that leads to the secondary hyperparathyroidism. Atrial fibrillation and cardiomegaly are common cardiac manifestations, but are more common in the elderly. Other symptoms include palpitations, tachycardia, nervousness, sweating, and dyspnea. Pericardial effusions are not typical findings in hyperthyroidism, and cardiac dilation may occur but only in severe prolonged hyperthyroidism that is untreated resulting in a cardiomyopathy. It is difficult to diagnose differentiated follicular carcinoma or to differentiate lymphoma from Hashimoto thyroiditis. Thyroid surgery (either complete removal or partial resection) is only indicated if the nodule is malignant, or there is local pressure symptoms related to the size of the nodule. A repeat assessment is not appropriate without confirming first that the nodule is not malignant. Classification of hypoglycemia includes spontaneous causes such as reactive or fasting hypoglycemia and pharmacologic or toxic causes. The diagnosis of insulinoma is most certain when Whipple triad is fulfilled: symptoms consistent with hypoglycemia, low plasma glucose, and relief of symptoms with elevation of plasma glucose to normal. Cushing disease and excess growth hormone will result in elevated blood glucose levels and diabetes (not decreased glucose values). Red cells are not involved, and involvement of the thyroid, liver, and pancreas is usually asymptomatic. It is the first counterregulatory hormone to respond to hypoglycemia, and it does this by increasing glycogenolysis and gluconeogenesis. In mild cases, dietary therapy may suffice, but the vast majority of patients require drug therapy. Statins are clearly the most effective medications available, but the majority of patients will not have optimal cholesterol control, even with maximum doses of a statin. Polyendocrine adenomatosis, type I, frequently includes islet cell tumors of the pancreas, leading to the Zollinger-Ellison syndrome, insulinomas, and glucagonomas. Estrogens cause thickening of vaginal mucosa and can improve urogenital and post-menopausal symptoms. Initially, strength may be increased, but this is transient, and a third of patients will experience weakness, likely secondary to myopathy. Muscle spasm and rhythmic contraction (fasciculation) are not clinical features of growth hormone excess. Vitamin D-resistant rickets is a familial disorder, with an X-linked recessive pattern, treated with pharmacologic doses of vitamin D. Risk of death in anorexia nervosa is also associated with hypothermia, suicide, or pneumonia with emaciation. In addition, severe weight loss can lead to both systolic and diastolic dysfunction of the ventricles. Diabetes is not a feature of eating disorders and acute kidney injury can sometimes develop in severe volume depletion states, but not typically seen. More commonly impaired uric acid excretion is an important risk factor for developing gout in patients with chronic kidney disease. The association of cardiovascular disease, hypertension, pyelonephritis, and hyperlipoproteinemia with gout contributes to the high prevalence of renal disease in these individuals. In severe osteomalacia, there is bowing of the long bones, inward deformity of the long bones, and wide osteoid borders on bone surfaces. Hypocalcemia is characteristic of osteomalacia; however, secondary hyper-parathyroidism often raises the serum calcium to low normal levels. Although it can develop gradually, acute renal failure can also be precipitated by hemodynamic stresses (bleeding, diuresis). The earliest manifestations are intrarenal vasoconstriction and avid sodium retention. Potassium retention is not a feature of the hepatorenal syndrome and oligoria occurs, not polyuria. In some cases, it is possible to identify carrier states and make prenatal diagnoses. The relationship between the abnormal gene and the metabolic defect (inability to regulate copper balance) is unclear. Other stimulators of protein kinases include platelet-derived growth factor and epidermal growth factor. Insulin-resistant states can be caused by prereceptor resistance (mutated insulin, anti-insulin antibodies) or receptor and postreceptor resistance. The action of insulin involves all three major metabolic fuels (carbohydrate, protein, fat). Radioactive iodine treatment or abrupt withdrawal of antithyroid medications is also implicated. The key diagnostic features are fever, tachycardia, and central nervous system dysfunction. In these individuals, bone age often correlates better with the onset and progression of puberty than does chronologic age. Approximately, one-third of unselected women with metastatic breast cancer will respond to tamoxifen. Androgen receptors on the tumor cells and premenopausal status do not affect response to tamoxifen therapy. A history of maternal breast cancer is also a risk factor for developing breast cancer. Calcium deposits are seen in the periarticular areas of the fourth and fifth metacar pophalangeal, third proximal interphalangeal, and fourth distal interphalangeal joints. There is slight soft tissue swelling, especially of the fourth and fifth metacarpophalangeal joints. In Cushing syndrome, secondary to an autonomous adrenal tumor, onset is usually gradual, and hirsutism, other androgenic effects, and hyperpigmentation are absent. The classic presenting symptoms are increased thirst, polyuria, polyphagia, and weight loss. In type 2 diabetes, the presentation can be more subtle and is often made when the patient is asymptomatic. Hypothyroidism can cause some of the symptoms experienced by this patient but not the weight loss, frequent yeast infections, or nocturia. Perineal pruritus in a diabetic is almost always associated with Candida albicans. It is caused by Pseudomonas aeruginosa and is characterized by ear pain, drainage, fever, and leukocytosis. Microaneurysms, dilated veins, dot and blot hemorrhages, cotton-wool spots, and hard exudates are common findings. Loss of desire can also be caused by psychologic disturbance, but may indicate androgen deficiency or drug effect. The lesions can be in large vessels (aortic occlusion, Leriche syndrome), small arteries, or even in the sinusoidal spaces. It is diagnosed by demonstrating minimal elevation of androgens and exclusion of other causes. Management is primarily by cosmetic therapy, although drugs to suppress androgen production and/or androgen effects on the hair follicle can be used. The spectrum of disease, however, is quite wide, and some patients have only mild hirsutism. When onset of hair growth (with or without frank virilization) is very rapid, a neoplastic source of androgen is suggested. In addition to ovarian tumors, the potential neoplasms include adenomas and carcinomas of the adrenal gland. Elevated levels of a precursor of cortisol biosynthesis such as 17 hydroxyprogesterone, 17-hydroxypregnenolone, or 11-deoxycortisol can present. Poor metabolic control is probably a major factor in the progression of diabetic nephropathy. Similar diets are often prescribed for diverticulitis or other conditions associated with a narrowed or stenosed colon. When acute symptoms subside, however, restrictions concerning dietary fiber should be stopped. Most patients should be referred to a dietician to help construct a diet appropriate in caloric intake. Early dumping occurs within 30 minutes of eating and is characterized by vasomotor symptoms such as palpitations, tachycardia, lightheadedness, and diaphoresis. Late dumping includes similar symptoms plus dizziness, confusion, and even syncope. It is presumed that this results in lower levels of serum ammonia, but other substances in the serum may be implicated. Chronic encephalopathy can be controlled with restricting protein intake and taking lactulose (osmotic laxative). Restricting daytime protein intake in patients with Parkinson disease may improve the efficacy of levodopa therapy. It can occur in infants 6–12 months of age who are on processed milk formulas, without citrus fruit or vegetable supplementation. The peak incidence in the United States is in poor and elderly people and alcoholics. It is common in children in developing countries and is a major cause of blindness. Asthma may be aggravated, acanthosis nigricans can occur, and in high doses, elevation of uric acid and fasting blood sugar can occur. Hepatic toxicity, including cholestatic jaundice, has been described with large doses. In North America, thiamine deficiency occurs in alcoholics or those with chronic disease.

This information needs to be explored with your patients sensitively cholesterol levels blood test fasting discount 10 mg atorlip-10 mastercard, as only they will be able to confirm the truth and agree to treatment cholesterol in shrimp and lobster order atorlip-10 10 mg free shipping. Read Good Medical Practice published by the General Medical Council cholesterol lowering foods 2015 cheap atorlip-10 10 mg with mastercard, which describes the standards of competence cholesterol in eggs pdf purchase atorlip-10 mastercard, care and conduct expected of you in all aspects of your professional work cholesterol glucose test kit cheap 10mg atorlip-10 with visa. Start with open questions but then gradually focus down on symptoms by using closed questions cholesterol lowering diet plan purchase 10mg atorlip-10 fast delivery. The list is not comprehensive but includes the most common symptoms for each system. Follow up any positive finding by asking closed questions to clarify if the symptom is significant. Each disease process or problem has specific characteristics that help you in this task. Diagnosis is based on recognizing the pattern of symptoms which each disease or problem commonly produces. You need to know these characteristics and then you will be able to ask useful questions. Initially you will not know enough to focus your questions and will have to use blanket questioning, but as you gain experience you can refine your questions according to the complaint. Build up your knowledge all the time by reading, seeing patients and listening to and observing colleagues. You should have a good idea of the diagnosis before you examine the patient and you should use your examination to support or refute it. Make sure that patients tell you what they feel the principal problem is in their own words without pressure or interruption. Prompt to keep the history flowing, and use your knowledge of disease to direct your questioning. When finished their initial description of the presenting complaint, start with the symptom that seems to concern them most. Each answer weights the probability of a particular diagnosis being more likely, while helping to exclude others. In this example the age of the man and the fact he is a long-term smoker increase the probability of certain diagnoses related to smoking. When the patient confirms his weight loss the positive predictive value of all these answers is very high for lung cancer and you will carry out your examination and plan investigations accordingly. If episodic, duration and frequency of attacks; if continuous, any changes in the severity Variation by day or night, during the week or month. Includes effects of medication and alternative medical approaches Ask about associated symptoms to help you work out the significance of any presenting complaint. Any severe pain can be associated with nausea, sweating and faintness as part of the vagal and sympathetic response. If the pain is sufficiently severe to disturb sleep, this suggests a physical cause but also, because patients are exhausted, this changes their perception of and ability to cope with the pain. This varies considerably not only between patients but in the same person in dif-ferent circumstances (Table 1. A family history of sudden death from heart disease may well affect how a person interprets and reacts to chest pain. For example, a person may concentrate on the tension headache rather than the source of stress that is exacerbating it. Recognizing somatization helps to avoid inappropriate investigations which may ultimately reinforce illness behaviour. These may simply be more attention from family and friends through to considerable financial benefits and being able to avoid unpleasant work or stress. Patients may not be conscious of these as demotivating factors in their illness but sometimes they deliberately exaggerate symptoms. There is often a relationship between the past medical history and the presenting problem. For example, a patient presenting with dyspepsia may have had a past history of multiple attendances for minor injuries. This should raise the possibility of an alcohol problem which could also account for the current symptoms. Strike a balance between asking open questions about the past history and obtaining relevant, meaningful information (Table 1. Asking if your patients have ever had an illness may invite a description of every cold, cough and headache that has troubled them, while asking only about serious illness is to unfairly ask them to decide about the nature of any previous ill health. Ask about prescribed drugs and any other medications your patient is taking (Table 1. Include over-the-counter remedies and alternative medicine treatments, particularly herbal or homeopathic remedies, laxatives, analgesics and vitamin/mineral supplements. Note the name of each drug, the dose, dosage regimen and duration of treatment along with significant side-effects. If patients claim to be taking unlikely combinations or amounts of drugs, confirm this with the last doctor to look after them. A drug addict may claim to be receiving a prescription for benzodiazepines and opioids in the hope of receiving the same from the admitting doctor. The modern term, concordance, means a shared decision between doctor and patient where they arrive at an agreement that respects the wishes and beliefs of the patient. However, this does not provide evidence that the patient has obtained the drugs from the pharmacist or taken them at the correct time. Drug allergies/reactions Always ask if your patient has ever had an allergic reaction to medication. In particular enquire about previous reactions before prescribing an antibiotic, particularly penicillin. Example of a drug history Drug Dose Duration Indication Notes Aspirin 75 mg 5 years Started after daily myocardial infarction Amitriptyline 25 mg at 6 Takes for poor sleep Feels drowsy in night months morning Atenolol 50 mg 5 years Started after Causes cold hands (? Otherwise the patient may receive a substance which precipitates a life-threatening adverse reaction. Some patients require prompting with suggestions about common familial diseases. In these circumstances ask if your patient or any close relative has been adopted. The social history Upbringing Birth injury or complications Early parental attachments and disruptions Schooling, academic achievements or difficulties Further or higher education and training Behaviour problems Home life a Emotional, physical or sexual abuse Experiences of death and illness Interest and attitude of parents Occupation Current and previous (clarify exactly what a job entails) Exposure to hazards. In trouble with the law House Type of home, size, owned or rented Details of home including stairs, toilets, heating, cooking facilities, neighbours Community support Social services involvement. A social history can be expansive, incorporating everything from childhood experiences to coffee intake. It is rarely appropriate to ask an elderly woman with a hip fracture whether she is injecting drugs but it is always necessary to know if she lives alone, has any friends or relatives nearby, what support services she receives and how well suited her house is for someone with poor mobility. There may be an infirm relative at home for whom the patient cares or there may be no one at home to look after the patient because, although she is married, her husband works abroad for 3 weeks out of 4. Occupational history the work people do may have a profound influence on their health. Symptoms which improve over the weekend or during holidays should always suggest an occupational disorder. The incubation period is useful in deciding on the likelihood of an illness (Table 1. As well as the country your patient visited you should ask about the type of accommodation. Sexual history It is not always appropriate to take a full sexual history (see Ch. If they smoke ask what (cigarettes, cigars or pipe); the quantity (number of cigarettes/cigars or amount of pipe tobacco per day) and the duration. Calculating pack years of smoking 20 cigarettes = 1 packet For example, a smoker of 10 cigarettes a day who has smoked for 15 years would have smoked: page 17 page 18 Click to view full size Figure 1. Do this by asking open questions giving permission for them to tell you, and do not appear to judge them. If they still have difficulty answering, ask them: When did you last have a drink? The content of a detailed alcohol history Quantity and type of drink Amount of money spent on alcohol Daily/weekly pattern (especially binge drinking and morning drinking) Usual place of drinking Alone or accompanied Purpose Attitudes to alcohol the first uses standard measures but is inaccurate and often underestimates intake. The second method is based on direct calculation of the alcohol content of drinks. This is more accurate given the range of alcohol strengths in beers, cider and wine, but it is less convenient. If a person drinks one glass of wine per night, the first method would estimate the intake to be 7 units per week. Many bottles of alcohol are now labelled with the number of units per bottle or per standard glass. In anyone it increases the chance of depression and obesity, and impairs cognitive function. The pattern of drinking is important because binge drinking of a large amount of alcohol causes acute intoxication. Difficulty in controlling starting or stopping drinking and in the amount that is drunk. Tolerance, so that increased doses are needed to achieve the effects originally produced by lower doses. This produces tremor, sweating, rapid heart rate, anxiety, insomnia, and occasionally seizures, disorientation or hallucinations (delirium tremens). Early detection of alcohol problems is important because of the health risks to patients and their families (Fig. Do you ever have a drink first thing in the morning to steady you or help a hangover? But remember that about 30% of the adult population in Britain have used illicit drugs (mainly cannabis) at some time. Symptoms associated with drug use should prompt you to ask further questions (Table 1. Experienced clinicians often carry out the systematic inquiry as they talk about the presenting complaint, but this takes practice and knowledge of the conditions you are trying to exclude or diagnose. Follow up any positive response by asking questions to increase or decrease the probability of certain diseases. The patient with palpitation: are there any endocrine symptoms to suggest thyrotoxicosis, or a family history of thyroid disease? How often during the last year have you been unable to remember what happened the night before because you had been drinking? How often during the last year have you failed to do what was normally expected of you because of drinking? In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? This allows the patient to: correct anything you have misunderstood add anything that may have been forgotten. Clarify any medical or other terms the patient uses so that you both understand what is meant. Mental and behavioural disorders are very common, with a prevalence of about 20% in the adult general population: they account for about 40% of consultations in primary care. However, severe mental disorders pose serious threats to the health and safety of the patient, and sometimes to the well-being of others. Physical and mental disorders often coexist sometimes coincidentally but more often as cause and effect. For example, a severe infection may precipitate delirium (an acute confusional state), while intravenous drug abuse may result in the patient acquiring infections. Consequently the prevalence of mental disorders (particularly organic brain disorders, mood illnesses and substance misuse disorders) is even greater among the physically ill, and affects mortality and morbidity. Because of these considerations all clinicians should be competent at basic psychiatric assessment of a patient. Assessment interviews usually do have to cover background personal and social factors to establish an understanding of how the illness evolved and to guide management, but the focus, as in all history taking, is the presenting problem and its solution for the patient. Additionally, it is helpful to establish whether: the patient knows about and accepts the referral the patient is able to understand and communicate the patient wishes to be seen alone or with somebody else there is an element of danger behavioural disturbance or other impediments to interview are likely. Otherwise, the interview follows conventional procedures: Put the patient at ease. Allow breaks and digressions (within reason) if the patient requires these notably with sensitive topics or when distress emerges. Concentrate on the presenting complaint, using a technique of nested, open questions to explore the key elements. Once the presenting situation is clear, the patient is settled and rapport permits, take greater control of the interview content through focused questioning and greater use of closed questions. Content the content of a psychiatric history is as follows: Reason for referral Presenting complaint(s) History of presenting complaint(s) Family history (including psychiatric disorders specifically) Personal history childhood; education; occupational history; sexual and marital history; children; current social circumstances Past medical/psychiatric history Prescribed medication; other remedies Psychoactive substance use, including alcohol, tobacco and caffeine Forensic history Premorbid personality. Some aspects of psychiatric history taking differ from standard medical interviewing, and merit further consideration. Risk assessment Mental disorders can be associated with danger: classically depression with harm to self, and paranoid states with harm to others. Whenever the presentation suggests such hazards may be a possibility, then inquiries about thoughts, impulses and actions concerning suicide or violence must be made. How and when this is broached during the interview depends on cues: generally it is best left until rapport is firmly established, as patients often find these matters difficult to reveal. Many patients are relieved to be able to confide what is frightening to them and unacceptable to share with their family. Sensitive issues There are other themes that can be tricky for the patient and doctor during an interview, notably sexual matters and criminal activities. The sexual history is a component in a standard psychiatric history, the forensic history is another, while illicit drug-taking is part of the history of psychoactive substance use. It is far more important to build an effective relationship than to obtain a complete account at the expense of alienating the patient.

Buy atorlip-10 from india. VIDEO: Should You Take Statin Drugs for Cholesterol? | drsinatra.com.

Lower homologous blood requirement in autologous blood donors after treatment with recombinant human erythropoietin cholesterol education month 10mg atorlip-10 free shipping. The cost-effectiveness of preoperative autologous blood donation for total hip and knee replacement cholesterol test cost discount atorlip-10 10mg without prescription. Transfusion of previously deposited autologous blood for patients undergoing hip-replacement surgery cholesterol levels for athletes order 10 mg atorlip-10 free shipping. Efficacy of postoperative blood salvage following total hip arthroplasty in patients with and without deposited autologous units cholesterol levels chart spain purchase online atorlip-10. National Heart cholesterol levels meat buy atorlip-10 10mg, Lung cholesterol test kit nz buy atorlip-10 with a mastercard, and Blood Institute Expert Panel on the use of Autologous Blood. A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty. Autologous interleukin-1 receptor antagonist improves function and symptoms in osteoarthritis when compared to placebo in a prospective randomized controlled trial. Intraarticular injection of anakinra in osteoarthritis of the knee: a multicenter, randomized, double-blind, placebo-controlled study. Visually-guided irrigation in patients with early knee osteoarthritis: a multicenter randomized, controlled trial. A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Articular debridement versus washout for degeneration of the medial femoral condyle. Outcomes of mechanical debridement and radiofrequency ablation in the treatment of chondral defects: a prospective randomized study. The effectiveness of the use of electrocautery with chondroplasty in treating chondromalacic lesions: A randomized prospective study. Autologous chondrocyte implantation for full thickness articular cartilage defects of the knee (knee). Treatment selection in articular cartilage lesions of the knee: a systematic review. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasyt for osetochondral defects in the knee. Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance. Comparative evaluation of autologous chondrocyte implantation and mosaicplasty: a multicentered randomized clinical trial. Hamstring anterior cruciate ligament reconstruction: Is it necessary to sacrifice the gracilis? Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. Arthroscopic second-generation autologous chondrocyte implantation compared with microfracture for chondral lesions of the knee: prospective nonrandomized study at 5 years. Treatment of focal degenerative cartilage defects with polymer-based autologous chondrocyte grafts: four-year clinical results. Autologous chondrocyte implantation of the knee: multicenter experience and minimum 3-year follow-up. Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique. The microfracture technique for the treatment of articular cartilage lesions in the knee. Articular cartilage repair in soccer players with autologous chondrocyte transplantation: functional outcome and return to competition. Results and performance after microfracture in National Basketball Association athletes. Evaluation of microfracture of traumatic chondral injuries to the knee in professional football and rugby players. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. The microfracture technique in the treatment of full-thickness chondral lesions of the knee in National Football League players. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. Effect of accelerated weightbearing after matrix-associated autologous chondrocyte implantation on the femoral condyle on radiographic and clinical outcome after 2 years: a prospective, randomized controlled pilot study. Collagen-Covered versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a comparison of tourniquet times. We do not have evidence based methods for the treatment of cartilage defects in the knee. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Effectiveness of autologous chondrocyte implantation in cartilage repair of the knee: a systematic review of controlled trials. Malalignment and cartilage lesions in the patellofemoral joint treated with autologous chondrocyte implantation. A randomized trial comparing autologous chondrocyte implantation with microfracture. Autologous chondrocyte implantation versus microfracture for knee cartilage injury: a prospective randomized trial, with 2-year follow-up. Characterized chondrocyte implantation results in better structural repair when treating symptomatic cartilage defects of the knee in a randomized controlled trial versus microfracture. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Comparison of osteochondral autologous transplantation, microfracture, or debridement techniques in articular cartilage lesions associated with anterior cruciate ligament injury: a prospective study with a 3-year follow-up. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Kaiser Permanente National Total Joint Replacement Registry: aligning operations with information technology. Survival and functional outcome after revision of a unicompartmental to a total knee replacement: the New Zealand National Joint Registry. Patient satisfaction compared with general health and disease-specific questionnaires in knee arthroplasty patients. The routine of surgical management reduces failure after unicompartmental knee arthroplasty. The Swedish Knee Arthroplasty Register 1975-1997: an update with special emphasis on 41,223 knees operated on in 1988-1997. Bone morphology in relation to the migration of porous-coated anatomic knee arthroplasties : a roentgen stereophotogrammetric and histomorphometric study in 23 knees. Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Satisfaction with care after total hip or knee replacement predicts self-perceived health status after surgery. Two-year incidence and predictors of future knee arthroplasty in persons with symptomatic knee osteoarthritis: preliminary analysis of longitudinal data from the osteoarthritis initiative. Clinical predictors of elective total joint replacement in persons with end-stage knee osteoarthritis. The long-term contribution of muscle activation and muscle size to quadriceps weakness following total knee arthroplasty. Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Greater perceived helplessness in osteoarthritis predicts outcome of joint replacement surgery. Catastrophic thinking about pain as a predictor of length of hospital stay after total knee arthroplasty: a prospective study. Five-year results of a prospective, randomised trial of 102 osteoarthritic knees with unicompartmental arthritis. Unicompartmental or total knee replacement: the 15-year results of a prospective randomised controlled trial. Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study. Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses. A prospective randomised double-blind study of functional outcome and range of flexion following total knee replacement with the NexGen standard and high flexion components. Knee range of motion during the first two years after use of posterior cruciate-stabilizing or posterior cruciate-retaining total knee prostheses. Posterior-stabilized versus cruciate-retaining total knee arthroplasty: balancing the gap. A randomized controlled trial comparing "high-flex" vs "standard" posterior cruciate substituting polyethylene tibial inserts in total knee arthroplasty. Concave versus posterior-stabilized tibial joint surface in total knee arthroplasty: randomized evaluation of 47 knees. A randomized, prospective study of primary total knee components designed for increased flexion. The intra-operative joint gap in cruciate-retaining compared with posterior-stabilised total knee replacement. Posterior stabilized component increased femoral bone loss after total knee replacement. The influence of the posterior cruciate ligament and component design on joint line position after primary total knee arthroplasty. A posterior-stabilized total knee arthroplasty shows condylar lift-off during deep knee bends. Proprioception, kinesthesia, and balance after total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses. The influence of an anterior-posterior gliding mobile bearing on range of motion after total knee arthroplasty. Staged bilateral mobile-bearing and fixed-bearing total knee arthroplasty in the same patients: a prospective comparison of a posterior-stabilized prosthesis. Comparison of anterior-posterior-glide and rotating-platform low contact stress mobile bearing total knee arthroplasties. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. Simultaneous mobile and fixed-bearing total knee replacement in the same patients. A prospective comparison of mid-term outcomes using a similar design of prosthesis. Less anterior knee pain with a mobile-bearing prosthesis compared with a fixed-bearing prosthesis. Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs. Fixed-bearing versus mobile-bearing total knee arthroplasty: a prospective randomised, clinical and radiological study with mid-term results at 7 years. Range of motion in total knee arthroplasty: a prospective comparison of high-flexion and standard cruciate-retaining designs. Patient-reported outcomes after fixed versus mobile-bearing total knee replacement: a multi-centre randomised controlled trial using the Kinemax total knee replacement. Comparison of a mobile with a fixed tibial bearing unicompartimental knee prosthesis: a prospective randomized trial using a dedicated outcome score. Rotating platform knees did not improve patellar tracking: a prospective, randomized study of 240 primary total knee arthroplasties. Comparison of mobile-bearing and fixed-bearing total knee arthroplasty: a prospective randomized study. Clinical and radiological results of high flex total knee arthroplasty: a 5 year follow-up. Comparison of bupivacaine plus buprenorphine with bupivacaine alone by caudal blockade for post-operative pain relief after hip and knee arthroplasty. Preoperative oral administration of fast-release morphine sulfate reduces postoperative piritramide consumption. Respiratory and analgesic effects of meperidine and tramadol in patients undergoing orthopedic surgery. Nausea and vomiting after major arthroplasty with spinal anaesthesia including morphine: a randomised trial of subhypnotic propofol infusion as prophylaxis. Cementless Oxford unicompartmental knee replacement shows reduced radiolucency at one year. Extramedullary or intramedullary tibial alignment guides: a randomised, prospective trial of radiological alignment. Treatment of urinary complications after total joint replacement in elderly females. Millimetre wave therapy for pain relief after total knee arthroplasty: a randomised controlled trial. The role of cold compression dressings in the postoperative treatment of total knee arthroplasty. A compression bandage improves local infiltration analgesia in total knee arthroplasty.