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Con- versely procardia 30 mg with visa coronary artery occlusive disease, reduced LC activity periods (REM sleep) allow time for a suppres- sion of sympathetic tone discount 30 mg procardia with visa cardiovascular 2. Abercrombie and Jacobs (1987a, 1987b) demonstrated a noradrenergically mediated increase in heart rate in cats exposed to white noise. Elevated heart rate decreased with repeated exposure, as did LC activation and cir- culating levels of norepinephrine. Libet and Gleason (1994) found that stim- ulation via permanently implanted LC electrodes did not elicit indefinite anxiety. This indicates that the brain either adapts to locus excitation or en- gages a compensatory response to excessive LC activation under some cir- cumstances. In addition, central noradrenergic responsiveness changes as a function of learning. In the cat, pairing a stimulus with a noxious air puff results in increased LC firing with subsequent presentations of the stimu- lus, but previous pairing of that stimulus with a food reward produces no al- teration in LC firing rates with repeated presentation (Rasmussen et al. These studies show that, despite its apparently “prewired” behav- ioral subroutines, the noradrenergic brain shows substantial neuroplas- ticity. The emotional response of animals and people to a painful stimulus can adapt, and it can change as a function of experience. PAIN PERCEPTION AND EXPERIENCE 73 From a different perspective, Bremner et al. Chronic exposure to a stressor (including per- severating nociception) could create a situation in which noradrenergic synthesis cannot keep up with demand, thus depleting brain norepineph- rine levels. Animals exposed to inescapable shock demonstrate greater LC responsiveness to an excitatory stimulus than animals that have experi- enced escapable shock (Weiss & Simson, 1986). In addition, such animals display “learned helplessness” behaviors—they cease trying to adapt to, or cope with, the source of shock (Seligman, Weiss, Weinraub, & Schulman, 1980). From an evolutionary perspective, this is a failure of the defense re- sponse as adaptation; it represents surrender to suffering. Extrapolating this and related observations to patients, Bremner and colleagues (1996) suggested that persons who have once encountered overwhelming stress and suffered exhaustion of central noradrenergic resources may respond excessively to similar stressors that they encounter later. The Ventral Noradrenergic Bundle and the Hypothalamo-Pituitary-Adrenocortical (HPA) Axis The ventral noradrenergic bundle (VNB) originates in the LC and enters the medial forebrain bundle. Neurons in the medullary reticular formation pro- ject to the hypothalamus via the VNB (Sumal, Blessing, Joh, Reis, & Pickel, 1983). Sawchenko and Swanson (1982) identified two VNB-linked norad- renergic and adrenergic pathways to paraventricular hypothalamus in the rat: the A1 region of the ventral medulla (lateral reticular nucleus, LRN), and the A2 region of the dorsal vagal complex (the nucleus tractus soli- tarius, or solitary nucleus), which receives visceral afferents. These medul- lary neuronal complexes supply 90% of catecholaminergic innervation to the paraventricular hypothalamus via the VNB (Assenmacher, Szafarczyk, Alonso, Ixart, & Barbanel, 1987). The noradrenergic axons in the VNB respond to noxious stimulation (Svensson, 1987), as does the hypothalamus itself (Kanosue, Nakayama, Ishikawa, & Imai-Matsumura, 1984). Moreover, nociception-transmitting neu- rons at all segmental levels of the spinal cord project to medial and lateral hypothalamus and several telencephalic regions (Burstein et al. These projections link tissue injury and the hypo- thalamic response, as do hormonal messengers in some circumstances. The hypothalamic paraventricular nucleus (PVN) coordinates the HPA axis. Neurons of the PVN receive afferent information from several reticular areas including ventrolateral medulla, dorsal raphé nucleus, nucleus raphé magnus, LC, dorsomedial nucleus, and the nucleus tractus solitarius (Lopez, 74 CHAPMAN Young, Herman, Akil, & Watson, 1991; Peschanski & Weil-Fugacza, 1987; Sawchenko & Swanson, 1982). Still other afferents project to the PVN from the hippocampus, septum, and amygdala (Feldman, Conforti, & Weidenfeld, 1995). Nearly all hypothalamic and preoptic nuclei send projections to the PVN. This suggests that limbic connections mediate endocrine responses during stress. In responding to potentially or frankly injurious stimuli, the PVN initiates a complex series of events regulated by feed back mechanisms.

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Psychological and cognitive development A variety of child development theories have been proposed but generic procardia 30mg without a prescription blood vessels keep popping in my hands, since the 1960s buy 30 mg procardia with visa cardiovascular disease and diabetes, education theory of child development in the UK has been dominated by Piaget’s cognitive development theory. Piaget believed that the development of cognitive ability (acquisition of knowledge including perception, intuition and reasoning) occurred in sequential stages and he linked these to the chronological age of a child rather than to the intellectual or emotional maturity of the child as favoured by modern theorists. Cognitive development, like physical growth, is individual to the child and their personal experiences. However, a child’s level of cognition directly influ- ences their understanding of, and reaction to, illness4 and there is considerable evidence that a child’s interpretation of health and illness progresses systemati- 5 cally. However, because not all children have the same experiences, some chil- dren will understand more than others at each age. As a result, age is not a good, nor an accurate, indicator of understanding. Birth to 3 years Avery young child has little direct understanding of illness but during this period strong attachments to family members are made and children experience stranger and separation anxiety when in new and unfamiliar situations. To main- tain the security and comfort of the child it is important to include the guardians in the care of their child. Explanation of the procedure should be made in a friendly manner and facial expressions should be welcoming. The attention span and memory of a toddler is short and therefore distraction techniques (e. Explanation of a procedure should be made using lan- guage that the child will understand and the use of pictures, books and toys to Understanding childhood 5 aid explanation5 and a demonstration of equipment to be used (if possible) will help allay fears and gain the child’s co-operation6. Children in this age group will still require the support of a guardian in strange situations and this involve- ment should be encouraged. Care needs to be taken not to under- mine the child and to provide appropriate information that will allow compre- hension and understanding of the medical procedure. For these children, fear of the unknown is still a real problem but expression of this fear or other emotion may be difficult and so a display of ‘bravado’ may occur to mask inner uncertainties. It is important for radiographers to appreciate that children may ‘put on an act’ of confidence when in strange situations but they will still require considerable care and attention and the involvement and support of a guardian. Adolescents The young adolescent experiences many emotional and physical changes and early adolescence is often associated with a period of low self-esteem and self- doubt8. These young people are much more sensitive and socially self-conscious than any other age group and therefore have particular needs within the health care setting. During the pubescent stage, the young adolescent is egocentric and physically self-conscious, not wanting to be perceived as different from his or her peers. Confidentiality and privacy is particularly important and reassurance and support is required from the health care professional9. Many young adolescents will want to have their guardian present during examination, particularly if it is an invasive procedure, but, as they progress through adolescence, they may prefer to be accompanied by a health care chaperone of the same sex. It should not be assumed that the teenager will or will not wish to be accompa- nied by a guardian and the choice, where possible, should be offered to the adolescent. Middle adolescents (15–17 years) are more confident of their personal identity, although those who, through disease or illness, are perceived to be ‘different from the norm’ will still require substantial emotional support. During this phase, a subculture of experimentation and boundary testing exists10. A consis- tent approach to the examination and a non-judgemental attitude is required of the radiographer dealing with this age group. The teenager should be involved in any decision-making process regarding their health care treatment and indeed, in English law, young people of age 16 years or older have the right to consent to medical, surgical and dental treatment (see Chapter 2). The end of this phase results in transition to late adolescence/adulthood and this stage 6 Paediatric Radiography brings with it new responsibilities and challenges (e. Unfortunately, it is also the stage at which the frequency of psycho-social disorders (e. Role of family The health of a child is dependent not only on the child’s physical and mental well-being, but is also influenced by cultural, social and environmental factors. In the past patients, including children, have been treated as clinical cases rather than individuals in their own right, and attention has been given almost exclu- sively to the medical condition.

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In the ankle (b) discount 30 mg procardia overnight delivery cardiovascular quizzes online, the anterior talofibular ligament (arrowheads) appears as a tight hyperechoic band that joins the talus and the fibula Ultrasonography of Tendons and Ligaments 43 examined order procardia 30mg blood vessels diagram, longitudinal and axial to the tendon or 3. High-resolution matrices (512 or 1024) Overuse Injuries and thin slices (1 to 3 mm) with minimal interslice gaps are optimum. For children of 1 year of age or Overuse injuries are the consequence of exceed- younger, oral chloral hydrate (50 mg/kg) is used ing the ability of tendon insertion to recover from for sedation. When the child is older than 6 years, submaximal cyclic loading in tension, compression, sedation is unnecessary in most cases. Monitoring shear or torsion, and depend on a variety of factors, the sedated child during the examination by staff including tissue strength, joint size, and the patient’s trained in anaesthesia with equipment safe for use age and skeletal maturity. Some tendons with a curvilinear course site involved is the knee, with injury to the inser- may exhibit focal signal changes caused by tissue tions of the patellar tendon, either the anterior tibial anisotropy when their fibres run at 55° with respect apophysis (Osgood-Schlatter disease) or the lower to the magnetic field (magic-angle effect). Examin- pole of the patella (Sinding-Larsen-Johansson dis- ers should be aware of this artefact to avoid confu- ease or jumper’s knee). Osgood-Schlatter disease usually affects boys with a history of participation in sports and a rapid growth 3. Sinding-Larsen-Johansson disease is similar Tendon Abnormalities to jumper’s knee. In both diseases, standard lateral radiographs can demonstrate a fragmented appear- A variety of disorders can affect tendons in children, ance of the apophysis. High-resolution US is an although they occur less commonly than in adults. It will demonstrate degenerative, inflammatory and infectious condi- focal hypoechoic swelling of the physeal cartilage, tions. The weakest point of the muscle–tendon– hypoechoic changes in the patellar tendon from bone unit in children is not the musculotendinous tendinosis and fluid collection from infrapatellar junction or the tendon substance, as seen in adults, bursitis (Fig. In the acute phase, local but the attachment of the tendon to the non-ossified hyperaemia can be demonstrated with colour and cartilage. Similar to the signs dren, and especially in school-aged athletes, involve observed in the knee, the posterior apophysis of the the tendino-osseous junction whilst degenerative calcaneus can undergo fragmentation (Sever’s dis- changes and ruptures in the tendon substance ease) leading to chronic heel pain. Two main types of abnormality US is also suitable for noninvasive follow-up of the are observed: acute trauma that results in partial or disease. MR imaging findings include increased T2- complete detachment of the apophysis by avulsion at weighted signal at the insertion of the tendon, in the the site of tendon insertion, and chronic lesions when surrounding soft tissue and in the adjacent bone repeated microtrauma secondary to overload leads marrow. Sonography is increasingly being used to confirm the clinical suspicion. Around the pelvis, high-resolution US is able to detect apophyseal avulsion at the ischial tuberosity (hamstrings muscles), the anterior supe- 44 M. Longitudinal 12-5 MHz grey-scale (a) and colour Doppler (b) images of the patellar tendon in a 15-year-old boy with focal tenderness and chronic pain over the tibial tuberosity reveal a swollen hypoechoic distal patellar tendon (arrowheads) and bony irregularity and fragmentation of the anterior tibial surface (asterisk); P patella. In the colour Doppler image (b), local increased flow signals (arrowheads) reflect intratendinous hyperaemia. A lateral radiograph (c) dem- onstrates a fragmented irregular apophysis (arrows) rior iliac spine (sartorius muscle and tensor fascia advantages of this technique include better images lata) and anterior inferior iliac spine (rectus femo- of deep-seated tendons or difficult-to-scan regions ris muscle), the iliac crest (abdominal and gluteus (Fig. At that commonly occurs at the poles of the patella these sites, the fracture edge may extend directly (proximally, insertion of the quadriceps tendon; dis- through the physeal cartilage, into the ossifying tally, insertion of the patellar tendon), the proximal apophysis or the underlying bone. US identifies a broad with posterior acoustic shadowing from avulsed sleeve of cartilage, often associated with an osseous bone fragments and local haematoma (Fig. In doubtful or difficult cases, MR minimal displacement, high-resolution US may imaging may be a useful adjunct to US. The main demonstrate a “double cortical sign” as a result of Ultrasonography of Tendons and Ligaments 45 a b c d Fig. Traction injury at the lower pole of the patella of a 14-year-old boy following a kick during a soccer game. Longitudinal 12-5 MHz US images obtained over the dorsal aspect of the distal left (a) and right (b) quadriceps tendon in a 8-year-old child with complete inability to knee extension after an acute injury. In the left quadriceps tendon (a), the normal contralateral tendon (arrowheads) shows well-defined borders and normal internal echo texture; P upper pole of the patella. In the right quadriceps tendon (b), the affected quadriceps tendon (arrowheads) appears swollen and hypoechoic. The tendon attaches to a hyperechoic bony structure (arrows) that lies deep and cranial to the upper pole of the patella (P).

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