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Other proteins (Factor V and Factor VIII) serve as bind- ing proteins purchase pristiq 50mg with amex, which assemble factor complexes at the site of injury buy pristiq 50mg mastercard. Ca 2+ and - carboxyglutamate residues in the proteins (formed by a vitamin K–dependent process in the liver) attach the factor complexes to phospholipids exposed on platelet membranes effective 100mg pristiq. Consequently, thrombus formation is rapidly accelerated and localized to the site of injury. Regulatory mechanisms within the blood coagulation cascade and antifibri- nolytic mechanisms prevent random coagulation within blood vessels that might obstruct blood flow. An x-ray showed no fractures, but a soft tissue swelling, consistent with a hematoma (bleeding into the tissues), was noted. Sloe’s mother related that soon after he began to crawl, his knees occasionally became swollen and seemed painful. The pediatrician suspected a disorder of coagulation. A screening coagulation profile suggested a possible deficiency of Factor VIII, a protein involved in the for- mation of blood clots. Sloe’s plasma Factor VIII level was found to be only 3% of the average level found in normal subjects. PLASMA PROTEINS MAINTAIN PROPER DISTRIBUTION OF WATER BETWEEN BLOOD AND TISSUES When the cells are removed from the blood, the remaining plasma is composed of water, nutrients, metabolites, hormones, electrolytes, and proteins. Plasma has essentially the same electrolyte composition as other extracellular fluids and con- stitutes approximately 25% of the body’s total extracellular fluid. The plasma pro- teins serve a number of functions, which include maintaining the proper distribution of water between the blood and the tissues, transporting nutrients, metabolites, and hormones throughout the body, defending against infection, and maintaining the integrity of the circulation through clotting. Many diseases alter the amounts of plasma proteins produced and, hence, their concentration in the blood. These The hydrostatic pressure in an changes can be determined by electrophoresis of plasma proteins over the course of arteriole is the force that “pushes” a disease. Body Fluid Maintenance between Tissues and Blood osmotic pressure, plus the tissue pressure, is the force that “pulls” water from intersti- As the arterial blood enters the capillaries, fluid moves from the intravascular space tial spaces into the venular side of the capil- into the interstitial space (that surrounding the capillaries) because of what are lary. Thus, if the hydrostatic pressure is known as Starling’s forces. The hydrostatic pressure in the arteriolar end of the cap- greater than the osmotic pressure, fluid will illaries (~37 mm Hg) exceeds the sum of the tissue pressure (~1 mm Hg) and the leave the circulation; if it is less, fluid will osmotic pressure of the plasma proteins (~25 mm Hg). At the venous end of the capillaries, the hydrostatic pressure falls to approximately 17 mm Hg while the osmotic pres- In cases of severe protein malnutri- sure and the tissue pressure remain constant, resulting in movement of fluid back tion (kwashiorkor), the concentra- from the extravascular (interstitial) spaces and into the blood. Thus, most of the tion of the plasma proteins decreases, as a result of which the osmotic force bringing water back from the tissues is the osmotic pressure mediated by the pressure of the blood decreases. The distended bellies of famine vic- As indicated in Table 45. The major protein synthesized is albumin, the extravascular tissues because of the severely decreased concentration of plasma which constitutes approximately 60% of the total plasma protein, but because of its proteins, particularly albumin. Albumin syn- relatively small size (69 kDa) is thought to contribute 70 to 80% of the total osmotic thesis decreases fairly early under condi- pressure of the plasma. Albumin, like most plasma proteins, is a glycoprotein and is tions of protein malnutrition. CHAPTER 45 / BLOOD PLASMA PROTEINS, COAGULATION AND FIBRINOLYSIS 829 Table 45. Specific Plasma Binding Proteins Synthesized in the Liver Ceruloplasmin Binds copper; appears to be more important as a copper storage pool than as a transport protein; integrates iron and copper homeostasis Corticosteroid-binding globulin Binds cortisol Haptoglobin Binds extracorpuscular heme Lipoproteins Transport cholesterol and fatty acids Retinol-binding protein Binds vitamin A Sex hormone–binding globulin Binds estradiol and testosterone Transferrin Transports iron Transthyretin Binds thyroxine (T4); also forms a complex with retinol- binding protein Many drugs also bind to albumin, which may have important pharmacologic impli- In spite of the importance of albu- cations. For example, when a drug binds to albumin, such binding will likely lower min in the maintenance of osmotic pressure in the blood, individuals the effective concentration of that drug and may lengthen its lifetime in the circula- lacking albumin (analbuminemia) have only tion. Drug dosimetry may need to be recalculated if a patient’s plasma protein con- moderate edema. The fre- quency of analbuminemia is less than one II.

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Subtalar arthroereisis for the cor- rection of planovalgus foot in children with neuromuscular disorders cheap pristiq 100 mg without prescription. Results and limitations of reha- bilitation in cerebral palsy buy pristiq 50mg. Rev Chir Orthop Reparatrice Appar Mot 1977 pristiq 100 mg mastercard;63: 609–22. Subtalar arthrodesis by cancellous grafts and metallic internal fixation. Surgical management of ankle and foot deformities in cerebral palsy. Hallux valgus: an acquired deformity of the foot in cerebral palsy. Hallux valgus and hallux flexus associated with cerebral palsy: analysis and treatment. Operative treatment for hallux valgus in chil- dren with cerebral palsy. Davids JR, Mason TA, Danko A, Banks D, Blackhurst D. Surgical management of hallux valgus deformtiy in children with cerebral palsy. Reflex sympathetic dystrophy syndrome in stroke patients with hemiplegia-three phase bone scintigraphy and clinical characteristics. SECTION II Rehabilitation Techniques Rehabilitation Techniques 805 Many interventions have been applied to treat cerebral palsy, but when all is said and done we are still dealing with a nervous system that is impaired in many different ways. Some of the interventions that we are applying to children with cerebral palsy (CP) are really attempts at remediation of the consequences of weakness or abnormal tone. The interventions we apply have their own side effects and limitations. As a consequence, we can fall into a trap and apply these interventions with an intensity that sends an un- fair signal to the child and family. In many cases, we simply teach and/or trick the child’s nervous system to cope and provide strategies that alter some of the side effects and, in some cases, simply de- lude ourselves. Neurodevelopmental Therapy Elizabeth Jeanson, PT In the 1960s and early 1970s, pediatric therapists for CP appeared distinct from therapists who trained on poliomyelitis cases and from there quickly developed a cadre of therapists who practiced neurodevelopmental therapy (NDT). Neurodevelopmental treatment has gone through a long evolution over the years. Time has forced it to become more eclectic and become one of the most commonly used intervention strategies for children from infancy through adulthood with CP. Berta Bobath in the 1940s, the scientific community’s understanding of the brain and the conceptual framework of NDT has evolved. As our under- standing of how the brain inspires and controls movement evolves, so does the theory of NDT into what is currently accepted as the Dynamic Systems Theory. Using the Dynamic Systems Theory, NDT-trained therapists are able to use a variety of handling techniques. These specialized techniques encour- age active use of appropriate muscles and diminish involvement of muscles not necessary for the completion of a task. Child-directed and -initiated movement tasks are critical to the success of neurodevelopmental treatment. Improvements in efficiency can include decreased en- ergy used during a task, decreased work required of the muscles during a task, and habituation of new patterns of movement. These tasks are specific to and driven by the functional needs of the child. In NDT the child takes an active role in treatment design. The therapist must be constantly evaluating their input into the child’s movement with the goal of active, habituated, in- dependent movement.

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As the process continues to age 15 years buy pristiq 50mg line, the severely os- teoporotic lateral aspect of the femoral head collapses and severe arthritic changes occur at the small contact area of the medial femoral head and the lateral acetabulum (H) buy discount pristiq 100 mg. This is the stage when most children develop severe pain with motion pristiq 50 mg, and sometimes severe pain at rest develops. Subluxation tends to increase at a rate of approximately 2% per month23 if the migration index is less than 50% or 60%. Once the migration index reaches 50% to 60%, the hip may go to full dislocation in childhood very quickly, sometimes going from 60% to 100% within several months. Adolescence The adolescent period, from the ages of 8 to 18 years, is a time when the skele- ton is much more mature with less cartilage in the hip joint and much more bone. During this time, the risk for the development of spastic hip disease in a hip that is otherwise normal goes from a relatively low risk at age 8 years to no risk by skeletal maturity. For children who come to preadolescence with some hip subluxation in the range of 30% to 60%, the subluxation may continue to progress; however, the progression is usually quite slow, less than 1% per month. For hips with mild to moderate subluxation, and if the hip is on the high side of the pelvic obliquity, it has an increased risk of developing further subluxation. How- ever, if the hip is on the down side of the pelvic obliquity, a subluxated hip may actually reduce and end up having a normal radiographic appearance. If the hip is normal, defined as an MP of less than 25% or 30%, the risk of develop- ing hip subluxation in adulthood is virtually nonexistent. If the hip has mild to moderate subluxation, defined as 30% to 60%, there may rarely be some progression in adulthood. However, indi- viduals who reach adulthood with hip subluxation of greater than 60% will, slowly over time, go to full dislocation in almost all cases. As an example, it is very difficult to provide ade- quate perineal care during menstrual cycles for a young adult woman with severe hip adduction contractures from fixed hip dislocation. As outlined above, the subluxated and dislocated hips become arthritic and, like many arthritic joints, become painful. There is a myth in the medical community that the hips do not ever become painful in individuals who are noncom- municative. The fact that these individuals develop painful hips from neg- lected dislocations is absolutely clear to physicians who routinely care for these individuals; however, it is often difficult to determine how much pain individuals are experiencing. Just as with elderly individuals who have de- generative joints, sometimes individuals with severe changes on radiographs have only mild pain and others with mild radiographic changes have severe pain. This same discrepancy is seen in people with spasticity and hip dys- plasia. Although the published literature varies widely, probably 50% to 75% of individuals with spastic hip dislocation experience enough pain that it is recognized by the caretakers or medical personnel. Diagnostic Evaluations The most important work in evaluating the diagnostic monitoring of children with the typical posterosuperior spastic hip disease was done by Reimers. Hip 531 spastic hips at risk is the physical examination. This examination, which was popularized by Rang et al. All spastic chil- dren should have this measure of hip abduction monitored every 6 months during childhood at least to age 8 years. This monitoring can be performed by a trained physical therapist; however, we personally prefer to monitor this in the CP clinic and keep a diligent record in a database. For children who demonstrate some limitation of hip abduction, meaning less than 45° on each side, the secondary evaluation process is a supine anteroposterior radiograph of the pelvis. Hip Radiograph The standard anterosuperior supine radiograph of the pelvis with the legs in neutral or relatively neutral position should be obtained every 6 to 12 months if the hip abduction is less than 45°. The MP of this radiograph must be measured and recorded (Figure 10. It is not appropriate to only look at the radiograph, because it is impossible to tell the difference between an MP of 20% and one of 35% without measuring.

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