Kent A. Stevens, M.D. Stevens, M.D.

• Director, Adult Trauma Services
• Associate Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0023389/kent-stevens

Candidates with congenital arterio-venous malformations affecting function are graded P8 menopause symptoms after hysterectomy evista 60 mg without prescription. Other congenital A-V malformations should be discussed with the single-Service consultant occupational physician responsible for the selection of recruits menstruation symptoms but no period discount evista 60mg online. All candidates with thrombophilia should be referred to the single-Service occupational physician responsible for the selection of recruits for an opinion as to medical suitability for Service breast cancer 7-year survival rates evista 60mg visa. Candidates with symptomatic varicose veins affecting lower limb function should normally be graded P8 menstrual vertigo buy evista once a day. Those with asymptomatic minor varicosities menstruation 18th century evista 60 mg sale, or who have undergone successful treatment pregnancy 10 weeks generic 60 mg evista, may be graded P2. It is important that conditions adversely affecting respiratory fitness are identified at the pre employment stage. Active disease, or a significant decrease in pulmonary function (standardised for age, gender and race) from whatever cause, is a bar to entry. Wheezing (including asthma) is common and recruiting medical officers must take a careful respiratory history including: a. In cases where the examining medical officer has concerns or the diagnosis is in doubt, guidance should be sought from the single-Service occupational physician responsible for recruiting. Candidates with symptoms confined to age less than 5yrs of age, or a single episode of wheeze associated with an acute respiratory tract infection (during which bronchodilator / inhaled steroid treatment may have been prescribed) may be graded P2. Candidates with a recorded history of asthma, with the following features, would be normally graded P8. Those who have experienced symptoms or taken, or been prescribed any form of treatment within the last 4 yrs. Those who have had a single admission to Intensive care or high dependency, or multiple admissions to hospital. All others with a history of wheeze, particularly those with an atopic tendency require investigation by the protocol below. If there is concern this may have been the case, efforts should be made to obtain the medical records from the event to gauge severity, and a candidate may be assessed by the protocol at 6. If left untreated, ipsi and contra-lateral recurrence rates of 84 this condition are high. Therefore, candidates who have had a spontaneous pneumothorax at any time without definitive treatment should normally be graded P8. Candidates who have suffered traumatic pneumothorax are at no greater risk of recurrence than the normal population. Therefore once these candidates have made a full clinical recovery, they may be graded P2 provided lung function is normal. Candidates with chronic bronchitis, emphysema, bronchiectasis, cystic fibrosis or other chronic pulmonary condition are graded P8. Full details of those with a history of confirmed, latent or suspected tuberculosis should be obtained and the candidate referred to the single-Service occupational physician responsible for the selection of recruits. Candidates with a current or past history of oesophageal disease, including, but not limited to ulceration, varices, fistula or achalasia are graded P8. Candidates with a current history of motility disorders, chronic, or recurrent oesophagitis are graded P8. Candidates who have had any form of surgical correction for hiatus hernia are graded P8. Those who have undergone surgery purely to resolve reflux and 88 who are asymptomatic and free of any complications 12 months post-surgery should be referred to the single-Service consultant occupational physician responsible for recruiting for a final decision on fitness for entry. Those with a history of dyspepsia that has caused frequent disability, no matter how long ago, are unfit for service and should be graded P8. Those with mild and infrequent symptoms not requiring any medication may be graded P2. The exception is where dyspepsia has been attributed to H pylori infection which has been successfully eradicated. In this case, candidates may be accepted if symptom-free for one year after treatment. Candidates with a history of surgery for peptic ulceration or perforation are graded P8. Medically resolved peptic ulcer disease should be assessed as for dyspepsia above. Candidates with pernicious anaemia may be graded P2 subject to the 89 following caveat. The history must be confirmed and an appropriate autoantibody screen and fasting blood glucose should not show any abnormality (apart from the antibodies involved in pernicious anaemia). Those with other antibodies or elevated fasting blood sugar should normally be graded P8 (due to the risk of developing other auto-immune conditions). Candidates with a current or past history of irritable bowel syndrome requiring medical follow-up/review, requiring medication within the previous two years 90 or of sufficient severity to interfere with normal daily activities are graded P8. Those with mild 91 symptoms not requiring any medication, who are able to cope with a varied diet may be graded P2 with a L2 risk marker. In cases of doubt an opinion should be sought from the single-Service Occupational Physician responsible for selection of recruits. As antibody tests can be false positive, it may be necessary to refer for confirmation of diagnosis. Opinion should be sought from the single-Service 92 Occupational Physician responsible for selection of recruits. Candidates with a history of gluten sensitive enteropathy (Coeliac Disease) or gluten sensitivity are graded P8. Candidates with a confirmed history of lactose intolerance and/or any other food intolerance which requires an exclusion diet to prevent symptoms and/or which require any form of medical intervention are graded P8. Candidates should normally be graded P8 if any hernia (inguinal, epigastric or incisional) is present. However, those with an easily reducible periumbilical hernia that does not affect physical activity may be graded P2. Candidates with repaired and soundly healed herniae may be graded P2 provided that they are able to tolerate activities comparable with military training/Service over a 94 minimum period of 3 months. However, candidates with a repaired incisional hernia (especially if originally extensive) should be referred for specialist surgical advice as this type of hernia is more liable to recur. Candidates with a history of open or laparoscopic abdominal surgery should be assessed following the guidance below. Care should be exercised to ensure that the original reason for such surgery is not disqualifying in itself. Candidates who have undergone surgery during the preceding 6 months are normally graded P8. Candidates who have had diagnostic laparoscopy and other procedures such as appendicectomy and laparoscopic sterilisation with a low risk of late complications may be assessed as P2 on return to full physical activity. Any candidate who has undergone bariatric surgery should be graded P8 as they all require prolonged follow-up and have significant long-term morbidity. Any applicant who has undergone colectomy and pouch surgery should be graded P8 as they all require prolonged follow-up and have significant long-term morbidity. Candidates with active disease or a history of more than two planned, definitive surgical procedures for pilonidal sinus are graded P8. Those who have had wide excision with healing by 92 Practice parameters for the treatment of patients with dominantly inherited colorectal cancer (Familial Adenomatous Polyposis and Hereditary Nonpolyposis Colorectal cancer). Candidates with active haemorrhoids (internal or external), when large, symptomatic, or with a history of bleeding within the last 8 weeks, are graded P8. Candidates with a developmental or chronic disease of the liver, biliary tree or pancreas are normally graded P8. Candidates with a current acute or chronic hepatitis, hepatitis carrier state, hepatitis in the preceding 6 months, or persistence of symptoms after 6 months, or 95 objective evidence of impairment of liver function are graded P8. Candidates with a single episode of acute viral pancreatitis with complete recovery and no evidence of chronic pancreatitis or diabetes may be graded P2 at least 1 year after recovery. Candidates with a current or past history of symptomatic cholecystitis, acute or chronic, with or without cholelithiasis, or other disorders of the gallbladder and biliary system are graded P8 unless surgically treated. Cholecystectomy is acceptable if performed greater than 6 months prior to examination and the candidate remains asymptomatic. Candidates who have had fibre-optic procedures to correct sphincter dysfunction or cholelithiasis if performed more than 6 months prior to examination and remain asymptomatic may be graded P2. A persistent abnormality of urinalysis is defined as painless haematuria 1+ and/or proteinuria 1+ (trace can be ignored). The candidate is graded P8 until pathology has been excluded to satisfaction of the single-Service occupational physician responsible for recruiting. However, they may be accepted subject to review by the single-Service Occupational Physician responsible for selection of recruits providing that: a. Those having made a complete recovery from acute glomerulonephritis or a single attack of pyelonephritis (without predisposing factors) more than two years earlier, may be graded P2. If protein excretion exceeds 98 400 mg/24 hours then the candidate should be rejected unless specialist consultation determines the condition to be benign orthostatic proteinuria. Those with a history of asymptomatic haematuria for several years and are normotensive, have no pathological proteinuria and normal renal function may be acceptable subject to formal nephrological assessment. If an abnormality is discovered then referral to the single-Service Occupational Physician responsible for selection of recruits is indicated. Candidates with unsuccessful or continuing treatment for urethral abnormalities are graded P8. Those who have been successfully treated for minor urethral stricture may be graded P2 on the condition that they have been discharged from follow-up. Candidates with genital piercing (excluding the urethra) that has fully healed without complications may be graded P2. Due to the risk of developing urethral stricture at a later date, candidates with history of genital piercing involving the urethra may only be accepted P2 on a case by case basis after obtaining the relevant urologists opinion. Candidates with a history of diurnal urinary incontinence, or of nocturnal enuresis in the two years preceding entry are graded P8 and barred from entry regardless of the presence of normal neurological and psychological investigations. A et al A new equation to estimate glomerular filtration rate Ann Intern Med 2009; 150 (9) 604-612 (Calculator found at touchcalc. Candidates with a current or past history of genital infection or ulceration, including, but not limited to herpes genitalis or condyloma acuminatum, if of sufficient severity to require frequent intervention or to interfere with normal function, are graded P8. Candidates with known polycystic disease, mega-ureter or other congenital anomalies are normally graded P8. Candidates with a family history of polycystic kidney disease require screening ultrasound after the age of 16 years before being accepted. Candidates with current hypospadias, when not accompanied by evidence of urinary tract infection, urethral stricture, or voiding dysfunction, may be graded P2 after urological assessment. All candidates should be referred to the single-Service Occupational Physician responsible for selection of recruits. All cases meeting the above criteria and potentially acceptable should be referred to the single-Service Occupational Physician responsible for selection of recruits. A candidate with a history of a single episode of ureteric spasm (renal colic), which has been investigated without demonstration of underlying pathology, may be graded P2. Candidates with successfully treated malignant disease of the bladder or kidney should be referred to the single-Service Occupational Physician responsible for selection of recruits. Candidates with non-specific groin or pelvic pain or undiagnosed loin pain are unsuitable for service and graded P8. Candidates with a history of some nervous system diseases may be acceptable for service but be excluded from employments that require more stringent medical standards including aircrew and occupational diving. Where there is doubt about either the diagnosis or suitability for entry, cases should be referred to the single-Service Occupational Physician responsible for the selection of recruits. Candidates with diseases of the nervous system with a progressive or recurrent course are normally graded P8. Candidates diagnosed as having epilepsy or who have had more than one seizure after their sixth birthday are to be graded P8. Candidates with febrile convulsions before their sixth birthday, and with no subsequent seizures, may be graded P2. They may still be unable to enter some trades or branches, subject to single-Service regulations. Such candidates must be referred to the single-Service Occupational Physician responsible for the selection of recruits. Those with a history of provoked seizures should be assessed on a case by case basis and advice sought from the single-Service Occupational Physician responsible for the selection of recruits. Consideration will also need to be given to fitness for service in relation to the provoking stimulus. It must be clear that the seizure had been provoked by a stimulus that does not carry any risk of recurrence and does not represent the unmasking of any underlying vulnerability. Candidates with a history of typical childhood absence 104 seizures with onset before the age of 10 years, who have had no such seizures for 5 years (without treatment) may be graded P2. Candidates with a confirmed diagnosis of typical rolandic epilepsy of childhood, who have been seizure-free for 5 years (without treatment) may be graded P2. Headaches are common and those who have infrequent mild headaches may be accepted as P2. Are severe enough to disrupt normal activities, including loss of time from school or work. Are aggravated by lack of sleep, missed meals or anxiety and occur more often than once every six months. The diagnostic criteria for migraine without aura are at least 5 attacks fulfilling criteria a-c: a.

You work with the patient to understand ideas related to the notion of self-as concept women's health center in center order discount evista line. Second women's health group boca raton 60 mg evista with visa, the observing self is beyond evaluation menstruation in africa cheap evista master card, remains stable and has no mechanical qualities breast cancer freebies order 60mg evista with visa. You may choose to provide feedback about progress on the assessments in terms of score improvement women's health issues endometriosis order evista 60mg on line. If so menopause the musical indianapolis evista 60mg visa, tailor this feedback to point to successes to motivate the patient to continue. Open with Mindfulness Session 7 opens with a 5-10 minute mindfulness exercise as in previous sessions (see Appendix B). Prior Session and Homework Review Following the mindfulness exercise, check-in with patients to see if they have any questions related to the previous session. Review the Mindfulness Tracking Form and ask about mindfulness practice since the last session. Check for successes and diffculties and explore options to help with diffculties if relevant. Review with patients the Willingness Worksheet 2 exploring reactions to the homework. Explore patient progress in bringing values to life in terms of both emotional and practical outcomes. Session Overview and Content: Self-as-Context Willingness to experience as an alternative to control is not always easily done, especially by simple instruction. The patient and therapist need to fnd a safe place from which willingness is more possible, a place where negative experiences are less threatening. The goal of self-as-context is to help the patient distinguish the self from experiential phenomena. If the patient is able to contact the sense of self as experiencer, then willingness to encounter diffcult emotional material is made easier. If not the emotion experienced, but rather the experiencer of the emotion, then emotion is not so dangerous or challenging. Internal experiences are like leaves passing on a stream, they ride gently atop the stream, and they are not the stream (link to previous session). Mindfulness/awareness can be helpful here, when paying attention, you can begin to notice even subtle changes in experience across time. These messages are without number and you will want to pay attention to the programming that is personally relevant to the patient. You can fnd this kind of programming by listening for statements/evaluations that patients keep making about themselves. Be sure to spend some time exploring this programming as part of the exercises below. This can be done by having patients give examples of programming they got from parents, friends, partners or being in the military. What is the relationship the patient has with the programming, one of fusion, or one of observation Ultimately in this session, you are working to distinguish the observer from the observed. From the place where the patient is self-as-context rather than content, they are free to choose outside of their programming. This programming comes from parents, it comes from teachers and friends, it comes from colleagues and even ourselves. This programming contains all kinds of content including content that is positive and negative and self and other-evaluative, etc. This programming is non-deletable and it pops up on the screen whenever certain buttons are pushed. In order for him to be okay, he needs to fnd a way to make this experience different. She has the freedom to curiously observe it and not get stuck in the process of trying to change it. The patient is asked to recall the numbers and note that those numbers are now part of their programming and that when you push a certain button. Relate this to how diffcult it would be to undo other programming that contains evaluation of the self. Let patients know they are going to continue to build this concept of experiencing programming, and other internal experiences like emotions by using the following metaphor: Chessboard metaphor (Hayes et al. Have patients tell you their good thoughts and feelings, place some pieces on the board to represent them, and then their bad thoughts and feelings, place pieces on the board to represent them. Then describe how a war is fought between the pieces and that much effort is made to get certain pieces off of the board (negative thoughts, feelings and memories) by having the good pieces win. If the good pieces are losing, then one typically needs more strategies to try and control the outcome. The board is the place where these pieces are felt and experienced, but the felt experiences are not the board itself (patients are the place where experiencing occurs). The items represent emotions, thoughts, sensations, and memories and the box is the context for these. Ask the patient to refect on memories, roles, body shape/size/sensations, emotions, and thoughts as experiences the patient has; and at the same time see that the patient is larger than these experiences. The patient is the place where these experiences occur; not the experiences themselves. Drawing this distinction helps patients to see that they are larger than negative thoughts and feelings. They are the experiencer of them (also the experiencer of positive thoughts and feelings), the context for the content. See example below: Therapist: (Pace this exercise and give plenty of time in between each instruction for the patient to formulate the image or connect to what is being asked or said). I would like you to close your eyes and take a few deep breathsLet yourself settle into the chair. Now I would like you to pick a memory from early this morning and spend time refecting on that memory (give a moment for the patient to pick a memory). Notice the sights and sounds of this memory, what is happening, who are you with, if anyone. Sometimes you are in the role of father, and other times you are in the role of friend. You have been in the role of patient and perhaps the role of parent (make the roles ft the patient). As you notice these roles, also notice that you behave differently in these roles. The role of father is different than the role of patient, how you behave with your mother is different than how you behave with your parent. You washed parts of your body away when you last showered and every cell in your body has changed over time, and as you notice this, notice who is noticing. A you that has been there for all of these changes in your body, yet is not just your body. You have experienced many emotions and as you notice this, also notice who notices. There is a you there that knows that you have emotion, yet is larger than emotion, you are not simply emotion. Your thoughts once came in one and two words and as you learned and grew, your thinking became more complex. Sometimes your thoughts are focused and engaged in solving a problem, sometimes your thoughts are lazy and just wandering around. At other times your thoughts may be racing and hard to slow down and there may be times when you are not aware that you are thinking at all. At times, your thoughts are evaluating and categorizing and at other times they are creative. At the end of the exercise, wind down by stating: Notice that you are not your memories, your roles, your body, your emotions or thoughts. Just as emotions and thoughts refect the immediate content of our verbal behavior, so, too, our Veteran Spotlight: Some histories function as repositories of verbal behavior. We carry our histories Veterans are attached to their around, and they can be incredibly useful, but they can also be painful or histories/ identities in ways that sometimes seem to push us ar und. Therefore the domain of memory and historical events soldier or a Vietnam Era Veteran are domains that call for acceptance, not control. By the time patients come into therapy, they have these Veterans may need help re extensive histories and rules that they are carrying around. Although certain histories and rules are valuable, others, when the patient might have or have had. With self-as-context, patients are taught to identify with their sense of consciousness and continuity. If the patient is whole now, no part of internal experience needs to be avoided, then choices about how to behave can emerge from a place of what matters and is valued rather than from a place of avoidance and control. Here we can give an example: many Veterans who are struggling may come to identify themselves, or get overly or exclusively attached to , a particular identity. Not only do they have a particular persona that embodies this identity, their life also seems to be defned by it. From the perspective of self-as-context you can work with patients to see themselves as having a history that contains many details of wartime and memories of that experience. They are fathers and mothers, sons and daughters, brothers and sisters, husbands and wives. Self-as-context can help loosen the grip that a particular history has on a patient, thus freeing them to make choices outside of the identity rather than from the identity. Share this with the patient and note that choice is always available from this place.

The malignant infantile autosomal recessive type is rare and characterised by dense sclerotic bones which fracture easily women's health clinic yonge street buy evista 60mg otc. In infants the appearances may be somewhat reminiscent of rickets and there may be radiolucent areas in the metaphyses breast cancer z11 study purchase 60mg evista visa. The three autosomal dominant forms are relatively mild and have a much better prognosis and the condition is often found co-incidentally breast cancer donations order evista uk. The primary genetic defects are known for the majority of types of osteopetrosis and several genes are involved women's health center dover nj buy 60mg evista with mastercard. It would be prudent to X-ray any bones of children otherwise thought to have rickets so that the chance to see a rarity is not missed pregnancy urine cheap 60mg evista with amex. The head of the ulna is prominent and projects backwards from the wrist and the carpal bones tend to have a triangular arrangement menstruation synonym buy evista 60 mg without prescription. The Madelung deformity may occur as an isolated phenomenon and is more common in females than males. Other Forms of Dwar sm It is important to remember that short stature may be normal in the sense that it occurs in an individual who is at the extreme left-hand end of the normal distribution for height. Dwar sm as the result of inadequate nutrition is most likely to present as a skeleton with normal proportions but with no other stigmata although osteoporosis may be apparent on X-ray. If the tumour develops before the epiphyses have fused, the result is gigantism, if after the epiphyses have fused, the result is acromegaly. He was known as the Irish giant and earned his living exhibiting himself but died at the early age of 22. The volume (in mm3) is then = 1/ (L D W) where L = maximum lateral length; D = maximum lateral 2 depth; and W = maximum ap width. The pituitary fossa is likely to be enlarged and the tufts of the terminal pha langes of the hands and feet may be considerably enlarged and both the hands and feet are larger than normal. These conditions are referred to as microcephaly, macrocephaly and craniosynostosis, respectively. The condition may present as an isolated phenomenon, or associated with other abnormalities when it is known as syndromic. Florid cases of microcephaly and macrocephaly are very obvious on simple examination but to diagnose those that are less extreme requires normative data against which to compare that skull circumference. Cranio-synostosis: this is caused by premature fusion of one or more of the six major sutures of the skull. Premature fusion may occur in the presence or absence of other abnormalities, syndromic76 and non-syndromic forms, 77 respectively. In life, craniosynostosis may be complicated by raised intracranial pressure but the intracranial volume is not reduced. Trigonocephaly Metopic Elongate, pointed forehead with a ridge in the centre of the forehead; parieto-occipital bossing. Brachiocephaly Bilateral coronal Skull assume an almost circular shape with a prominent frontal bone and attened occiput and anterior displacement of the vertex. In the skeleton the condition will be readily apparent by a defect in the hard palate which may or may not involve the anterior margin. At birth about 2%ofneonates have clinical evidence of hip instability but by three months, only one infant in 1000 has evidence of dislocation. In the infant, the acetabulum is shallow and the femoral head is undeveloped with variable degrees of subluxation. There are likely to be pseudoarthroses on the ilium, and the femoral heads are likely to be hypoplastic. Where secondary osteoarthritis develops this can be taken as an indication that the individual was able to walk, although almost certainly with a waddling gait, and survived for many years into adulthood. The aim of treatment is to stabilise the fracture so that the blood supply to the femoral head is not compromised with the risk of osteonecrosis. In some cases healing and regeneration are complete and it may not be possible to recognise the condition in later life but in others, changes are evident in the proximal femur. These areas are radiolucent on X-ray and they are described in life as having a ground-glass appearance. Distribution of lesions in different types of brous dysplasia Type of brous dysplasia Sites affected in order of frequency Monostotic Rib, femur, tibia, cranio-facial bones, humerus, vertebrae Polyostotic Femur, tibia, ribs, skull, facial bones, upper extremities, lumbar spine, clavicle, cervical spine Cranio-facial Frontal, sphenoid, maxilla, ethmoids Cherubism Maxilla, mandible types are recognised: monostotic (only a single bone is affected), polyostotic (several bones affected), craniofacial which may complicate either of the rst two types or occur in isolation, and cherubism, an autosomal dominant condition with variable penetrance that occurs in children and is more severe in males than in females. In life, the condition may cause pain and deformation of the affected bones and pathological fractures are common. However it is brought to light, the help of a skeletal radiologist should always be sought before committing a diagnosis to paper. The posterior part of the ribs on the convex side are pushed backwards while the anterior part is pushed anteriorly. The lamina and spinal canal on the concave side are narrower than on the contralateral side and the spinous process is rotated towards the concave side. The lamina and spinal canal on the concave side of thecurvearenarrowerthanonthecontralateralside. A line is drawn along the upper end plate of the proximal body and the lower end plate of the distal body and the angle of interest is the angle between these two lines. In those with a substantial deformity, severe cardiac and respiratory complications may arise 112 There are various ways of doing this, but one which I have found useful if to cut a section of plastic pipe insulation and pass it up (or down) through the spinal canal. Various other anomalies may be associated with the condition, including scoliosis, as noted above. If it seems that there are thirteen ribs, however, the seventh cervical vertebra should be examined for an articular facet since cervical ribs are more common than thirteen thoracic ribs. The mildest form of the condition in infants is also called spina bi da occulta which maybesilentbutmaybeapparentinsomechildrenbythepresenceofatuftof hair or a dimple over the defect in the underlying vertebra. On this account it is strongly recommended that some other term is used to describe the innocuous condition in the sacrum; bi d sacrum might be preferable but long usage of the usual phrase suggests it is not likely easily to be abandoned. The enlargement may be unilateral or bilateral, and one or both sides may be fused to the sacrum, giving rise to eight variations, 125 none of which can be missed in the skeleton. About 3%ofthegeneral population have six lumbar vertebrae127 but, again, the condition has no clinical signi cance. By contrast, there does seem to be an association between having six lumbar vertebrae and transitional vertebrae and there is some evidence that those with six lumbar vertebrae are more susceptible to spondylolysis. The principal constraint is that, in most parts of the world, mummi ed remains are greatly in the minority and most palaeopathologists will spend most of their working lives dealing with human remains that have no soft tissue attached to them. Even when available, the results may not always be instructive because of changes in the tissues resulting either from the mummi cation or from natural decay. In recent years, reports have appeared of the presence of several parasitic infestations in mummies, includ ing pinworm, 2 ascaris, trichuris and mites, 3 antigens to Ehistolyticain desiccated faeces, 4 ukes and hookworm, 5 Leishmaniasis6 and cysticercosis. He acquired diphtheria while studying the bacillus and had such severe paralytic sequelae that he resigned his post and went to Egypt to convalesce. He was eventually appointed professor of bacteriology in Cairo and began his study of Egyptian mummies, publishing many papers on the subject. He was knighted in 1916 and died at sea in 1917, when returning from a conference in Salonika. Schufeldt was also an interesting character, although completely different from Ruffer. Secondary bone tumours too are merely the skeletal re ection of tumours arising in soft tissues. Aneurysms: Aneurysms are dilations of a portion of an artery that may be congen ital or secondary to a disease such as atherosclerosis or syphilis, or to trauma. The ascending aorta or the aortic arch are the classic sites for the development of syphilitic aneurysms although they may also rarely involve the innominate artery. Descending and abdominal aorta: the descending aorta begins at the level of the fourth thoracic vertebra and is continuous with the abdominal aorta at the diaphragm, ending at the level of the fourth lumbar vertebra where it divides into the two common iliac arteries. Aneurysms of the aorta may occur in any part of its course but tend to be in the lower parts of the vessel. It enters the skull through the foramen magnum to form the basilar artery (with its opposite partner). Aneurysms may form on any part of the vertebral artery, and they may be traumatic or non-traumatic in origin. Only those that form on the section within the transverse foramina leave an impression on the skeleton, however. During its course through the transverse foramina, the artery may become coiled or looped and this may cause pressure defects in the adjacent vertebral body. The result may be complete disruption of the artery or the formation of an aneurysm. Blood ow is impaired distal to the constriction and collateral vessels develop to ensure that the trunk and lower limbs are adequately supplied. It was once thought that this was pathognomonic of coarctation but it is now known that, although coarctation is the most common cause, there are a number of others, mostly cardiovascular in origin. Meningioma: Meningiomas are tumours that are thought to arise from arachnoid cap cells which are specialised cells found in the arachnoid granulations. When the tumour arises in the vault, one or more of the branches of the middle meningeal artery may be enlarged and this may be associated in some cases with enlargement of the foramen spinosum, through which the artery passes. The increased density seen on skull X-ray when hyperostosis is present may affect both the inner and outer tables and the appearance may be similar to that seen in an osteosarcoma. The lesion is fed by a large aberrant vessel (black arrow) from the middle meningeal distribution and almost certainly was a meningioma. For example Campillo found ve cases among 3000 skulls47 giving a prevalence of 0. Acoustic neuroma (Vestibular schwannoma): Acoustic neuromas are also benign tumours, in this case arising from the Schwann cells that cover the eighth cranial nerve. The vestibular nerve is also composed of two nerves, the inferior and superior vestibular nerves; acoustic neuromas arise most commonly from the inferior vestibular nerve 230 palaeopathology intracanalicular. Acoustic neuromas are rare tumours with an estimated incidence of between 1 and 20 cases per million51 but this is almost certainly a considerable underestimate since many will go undetected if they do not cause signi cant symptoms of deafness or brain stem compression. Bone abnormalities arise because of overgrowth or destruction of bone caused by the underlying neuro bromas. Osteoporosis is common, particularly of the load bearing bones, 59 and pathological fractures, especially of the tibia, with impaired healing and the development of a pseudarthrosis are frequent. Myelomeningocele is usually fatal within the rst year of life if untreated and would have been universally fatal until quite recent times. Cholesterol stones contain about 70% of cholesterol and when cut, have a radial structure andlinescanbeseenradiatingfromthecentreofthestonetotheperiphery. They often have pigment at their centre and they range in colour from white to yellow. Most pigment stones are greenish-brown but there is a black variety which contains considerably more pigment and less cholesterol and they may also contain calcium carbonate and calcium phosphate. When pigment stones are cut, the brown stones have concentric layers of pigmented and non-pigmented material while black stones have a homogenous dark appearance throughout. Patients with cholesterol stones also tend to be younger than those with pigment stones, thus, patients under forty tend to have cholesterol stones, while those over seventy tend to have pigment stones and are also much more likely to have cirrhosis of the liver. Both kidney stones82 and bladder stones83 have been reported in human remains, including one from Norwich, although not from the period when the condition was at its peak. Brie y, before the introduction of sugar into the diet, caries tended to appear at the cemento-enamel junction, or the apposi tional surfaces. Once sugar was widely available it affected the ssures on the molars more frequently than elsewhere, and this is the pattern that continues to this day although the widespread uoridation of drinking water has reduced the prevalence of caries very considerably. The bacteria that live on teeth are largely streptococci and lacto bacilli10 and they are encapsulated in an organic matrix that is known as a bio lm. They metabolise fermentable carbohydrates to produce weak organic acids that may eventually cause the local pH to fall below the level necessary to demineralise the tissues of the tooth.

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