Wayne E. Cascio, MD

• Professor of Cardiovascular Science and Medicine
• Vice-Chairman, Department of Cardiovascular Sciences
• Brody School of Medicine
• Director of Research, East Carolina Heart Institute
• East Carolina University
• Chief of Cardiology, Pitt County Memorial Hospital
• Greenville, North Carolina

The rash first appears on the face as tiny maculopapular lesions that contain both discolored spots of skin called macules and red allergy symptoms pollen headache order nasonex nasal spray line, raised areas of skin called papules allergy symptoms for dogs buy cheap nasonex nasal spray 18 gm on-line. The lesions may be so densely clustered in certain areas that the skin surface appears generally swollen and red allergy symptoms vs flu cheap 18 gm nasonex nasal spray mastercard. Diagnostic Procedures the clinical picture of symptoms is usually a sufficient basis for a diagnosis of rubeola allergy list discount 18 gm nasonex nasal spray with visa. Blood testing may reveal an abnormal decrease in the number of circulating white blood cells allergy forecast germany purchase nasonex nasal spray 18gm free shipping, or leukopenia allergy forecast generic 18gm nasonex nasal spray visa, and antibody titers are used to detect the presence of measles antibody in both the acute and convalescent phases. Bed rest is indicated, sometimes in a darkened room to alleviate the discomfort of photophobia. Prevention Active immunization can be produced by administration of a vaccine, preferably containing the live attenuated virus. The increase in incidence in the past few years is the result of children not receiving vaccinations as well as increased international travel, which is increasing the rate of exposure. Rubeola can be prevented within 5 days of exposure by administration of gamma globulin, a protein formed in blood that functions as an antibody to provide rapid, temporary immunity to the disease. Hand washing and discarding tissues contaminated with respiratory secretions may help prevent the spread of measles within a family. It closely resembles rubeola, but it differs in its short course, mild fever, and relative freedom from complications. Educate caregivers about the incubation period, the spread of infection, and how to handle bedding, discarded tissues, and dishes. Prognosis Rubeola is usually a benign disease, running its course in about 5 days after the rash appears. Signs and Symptoms the onset of the disease is sometimes characterized by malaise, headache, slight fever, and sore throat. It may be composed of pale red, slightly elevated, discrete papules, or the rash may be highly diffuse and bright red. The rash begins on the face, spreads rapidly to other portions of the body, and usually fades so rapidly that the face may clear before the extremities are affected. Diagnostic Procedures Because rubella can be easily confused with other diseases, a definitive diagnosis can be reached with cultures of the throat, blood, and urine or with antibody titers. A culture of urine with antibody titers is generally done in the acute and convalescent phases. Prevention Lasting immunization can be conferred through use of a live rubella vaccine. Administration of gamma globulin shortly after exposure may prevent development of the disease, but it still may not prevent transfer of the virus to the fetus if exposure occurs during pregnancy. Prevention includes good hand washing and disposing of tissues contaminated with respiratory secretions. X Description Mumps is an acute contagious disease characterized by fever and inflammation of the parotid salivary glands. The disease is most common among children and young adults in late winter and spring. Etiology the disease is caused by the mumps paramyxovirus, which has an incubation period of 18 days. Signs and Symptoms the classic symptoms of mumps are unilateral or bilateral swollen parotid glands. Headache, malaise, fever, and earache may occur, and other salivary glands may become swollen. Diagnostic Procedures the clinical picture of mumps and a history of recent exposure usually are sufficient for diagnosis. Because many clients are asymptomatic, teaching opportunities may be limited; however, it is a good idea to encourage clients to eat a balanced diet and drink ample fluids. The disease is benign, seldom produces complications, and runs its course in 3 days. Rubella is dangerous, however, when it occurs in pregnant Infectious and Communicable Diseases 73 Complementary Therapy No significant complementary therapy is indicated. Complications can occur, however, and include orchitis, pancreatitis, and various central nervous system manifestations. Orchitis, which causes swelling of the testes in adult men, is extremely uncomfortable but rarely causes sterility, as is often feared. Good hand washing and proper disposal of contaminated tissues is essential for prevention. Etiology the disease is caused by the varicella-zoster virus, which is a herpesvirus. Its incubation period is 2 to 3 weeks, usually between 13 and 17 days, and is spread via respiratory secretion and direct contact. Signs and Symptoms the sign of chickenpox is a pruritic rash, which begins as erythematous macules that produce papules and then clear vesicles. The rash usually contains a combination of papules, vesicles, and scabs in all stages. Diagnostic Procedures the clinical signs are usually sufficient for the diagnosis. Treatment Isolation is important during the infectious period- usually until all the scabs disappear. Calamine lotion, cool bicarbonate of soda, or colloidal oatmeal baths can be very helpful. Complementary Therapy No significant complementary therapy is indicated other than oatmeal baths, as suggested previously. The disease occurs most commonly among children and may occur in epidemic outbreaks. Chickenpox requires strict adherence to proper hand washing, disposal of tissues, and proper cleaning of bedding and clothing. Teach clients or caregivers how to apply any lotions or medications to alleviate itching. Do not give children aspirin-containing products because of its link to Reye syndrome. Complications may include secondary bacterial infections of the skin as a result of scratching open lesions, thrombocytopenia, arthritis, hepatitis, and Reye syndrome. After a varicella infection, the virus can remain inactive in nerve cells near the spinal cord and reactivate later as shingles. Shingles can cause tingling, itching, and pain followed by a rash of red bumps and blisters. Anyone who has not had chickenpox can catch it from someone with shingles, but they cannot catch shingles. In certain situations, varicella-zoster immune globulin may be administered within 72 hours of exposure to stop the development of the disease. Good hygiene, including proper disposal of tissues contaminated with respiratory secretions, is important. It is called fifth disease because it was classified in the late 19th century as the fifth in a series of six childhood exanthems- rashes that occur on the skin as opposed to rashes that occur on the mucous membranes (or enanthems). Etiology Fifth disease is caused by the human parvovirus B19 (this not the same parvovirus pets may get) and is transmitted through respiratory secretions or direct contact. Parvovirus B19 can be transmitted during therapy with clotting factor concentrate. It is most prevalent in elementary and junior high school children during winter and spring. Signs and Symptoms the child has a low-grade fever, coldlike symptoms, and a red facial rash that looks like a "slapped cheek. Between 20% and 60% of the children in outbreaks are symptomatic, and many are asymptomatically infected. The B19-specific antibodies can be detected with commercially available immunoassay kits. Treatment Generally, no treatment is needed; however, it is important to manage any fever. Although the exact route of transmission is essentially unknown, it is important to discard any used tissues appropriately and to encourage clients to drink ample fluids and practice good hand washing. Prevention Good hygiene and proper disposal of tissues with contaminated respiratory secretions are necessary. X Description Pertussis is an acute, highly infectious respiratory tract disease characterized by a repetitious, paroxysmal cough and a prolonged, harsh, or shrill sound during inspiration (the "whoop"). Pertussis affects infants and children more frequently and more severely than it does adults. It induces a mucopurulent secretion and hampers the natural ability of the respiratory tract to clear such secretions. The route of transmission for the disease is direct contact with any discharge from the mucous membrane of an infected person. Signs and Symptoms the signs and symptoms of pertussis can be divided into three stages. The catarrhal stage is marked by the gradual onset of coldlike symptoms-mild fever, running nose, dry cough, irritability, and anorexia. This stage lasts from 1 to 2 weeks, during which the disease is highly communicable. The paroxysmal stage is marked by the onset of the classic cough, consisting of a series of several short, severe coughs in rapid succession followed by a slow, strained inspiration, during which a "whoop" (stridor) may be heard. This stage, lasting 3 to 4 weeks, may be accompanied by weight loss, dehydration, vomiting, epistaxis, and hypoxia. After several weeks, a period of decline begins, marked by the gradual diminishment of coughing. Diagnostic Procedures A history of exposure to another infected individual and the presence of the classic cough may be sufficient to establish the diagnosis. A very high white blood cell count is another distinguishing feature of pertussis. Treatment Antibiotics administered during the catarrhal stage may check the development of the disease; if administration is delayed past this stage, antibiotics have little effect. The individual with pertussis requires meticulous care to ensure adequate nutrition, hydration, and clearance of mucous secretions. Fruits, vegetables, brown rice, clear vegetable soups, potatoes, and whole grain toast may be tried. Aromatherapy with basil, chamomile, eucalyptus, peppermint, and lavender in a cool mist vaporizer may be useful. Educate clients about the necessity of following the treatment plan, including taking all of the prescribed medication. Prognosis the prognosis for an individual with pertussis varies from case to case. Complications can occur as a result of seizures, apnea, encephalopathy, and pneumonia. Fifteen infants younger than 3 months died before they were old enough for the vaccination. Prevention A child can be rendered less susceptible to pertussis by receiving a series of immunizations with pertussis vaccine. Good hand washing and proper disposal of contaminated tissue from respiratory secretions are essential. It is characterized by a gray to black membrane-like coating that forms over mucous membrane surfaces, particularly along the respiratory tract, which can block airways. It can cause a toxic reaction that primarily affects the heart and peripheral nerves. Most cases 76 Diseases of the Human Body occur in children under age 10, but older children and adults also may be affected. Transmission is through contact with discharge from the nose, throat, eye, and skin lesions. There may be a strong, foul odor to the breath; bluish skin color; bloody, watery nasal drainage; and breathing problems. Diagnostic Procedures the appearance of the characteristic membrane may be sufficient to establish a diagnosis of diphtheria. A definitive diagnosis can be made only by identifying the bacterium in nose and throat cultures. Treatment the only specific treatment is administration of sufficient quantities of diphtheria antitoxin as early in the course of the disease as possible followed by antibiotic therapy. Emergency measures may be required to maintain an airway or to control cardiac complications. Booster doses should be administered at appropriate intervals during early childhood. While today the incidence of diphtheria has greatly decreased, with only five cases reported in the United States in the last 10 years, it is a disease that must be recognized for its serious potential. Also, acknowledging the diseases prevented by the vaccination makes the public more aware of the consequences of refusing vaccinations. The disease may affect any person at any time-the elderly, migrant workers, children, and injection drug users. Puncture wounds are particularly prone to tetanus, but sores can become infected by the bacteria. Etiology the disease is caused by Clostridium tetani, a bacterium commonly found in soil. The bacillus becomes pathogenic when its spores enter the body through a puncture wound.

However jackfruit allergy treatment cheap nasonex nasal spray online visa, in rare situations allergy forecast denver order generic nasonex nasal spray, non-radial C7-innervated muscles may be relatively spared allergy institute purchase 18gm nasonex nasal spray fast delivery, making the clinical differentiation quite difficult allergy immunology purchase nasonex nasal spray 18gm. Although lesions of the posterior cord of the brachial plexus result in weakness of radial-innervated muscles allergy symptoms vertigo discount nasonex nasal spray 18gm visa, the deltoid (axillary nerve) and latissimus dorsi (thoracodorsal nerve) should also be weak allergy forecast maryland nasonex nasal spray 18gm with visa. The typical upper motor neuron posture results in flexion of the wrist and fingers, which in the acute phase or when the lesion is mild may superficially resemble a radial neuropathy. Central lesions are identified by increased muscle tone and deep tendon reflexes (unless acute), slowness of movement, associated findings in the lower face and leg, and altered sensation beyond the radial distribution. Superficial Radial Sensory Neuropathy the superficial radial sensory nerve is derived from the main radial nerve in the region of the elbow. Its superficial location next to bone makes it extremely susceptible to compression, a syndrome coined "CheiralgiaParesthetica,"whichtranslatesfromtheGreek as cheir + algos, meaning pain in the hand. Posterior Interosseous Neuropathy Wrist drop or finger drop Radial deviation on wrist extension Weakness of supination (mild) Weakness of elbow flexion (mild) Diminished brachioradialis tendon reflex Weakness of elbow extension Diminished triceps tendon reflex Weakness of shoulder abduction Sensory loss in lateral dorsal hand Sensory loss in posterior arm or forearm Weakness of wrist flexion X, May be present. Radial motor study recording extensor indicis proprius, stimulating the forearm, elbow, below spiral groove, and above spiral groove; bilateral studies 2. Ulnar motor study recording the abductor digiti minimi, stimulating the wrist, below groove, and above groove in the flexed elbow position 3. Median motor study recording the abductor pollicis brevis, stimulating the wrist and antecubital fossa 4. Superficial radial sensory study recording over the extensor tendons to thumb, stimulating the forearm; bilateral studies 6. The active electrode is placed over the extensor indicis proprius, 2 cm proximal to the ulnar styloid, with the reference electrode over the ulnar styloid. The radial nerve can be stimulated in the forearm, at the elbow, and below and above the spiral groove. Nerve Conduction Studies the most important nerve conduction study in assessing a wrist drop is the radial motor study (Box 24. The radial nerve can be stimulated in the forearm, at the elbow (in the groove between the biceps and brachioradialis muscles), and below and above the spiral groove. Several significant technical points must be considered when performing radial motor studies. This occurs because volume-conducted potentials from other nearby radialinnervated muscles. Because the radial nerve winds around the humerus and takes a somewhat circuitous course through the arm, surface distance measurements often are inaccurate. Measuring distance with obstetric calipers, especially between theelbowandarm,reducessomeofthiserror. Radial conduction velocities sometimes are calculated as factitiously fast (>75 m/s). However,stimulationabovethespiral groove will result in electrophysiologic evidence of a conduction block, i. Recording extensor indicis proprius and stimulating the forearm, elbow, below spiral groove, and above spiral groove. Note the marked drop in amplitude and area across the spiral groove on the left (conduction block) and the symmetric distal compound motor action potential amplitudes from side to side. Taken together, these findings imply a predominantly demyelinating lesion at the spiral groove. The radial sensory nerve action potential is easy to record and typically has a triphasic morphology. It is expected to be normal in all posterior interosseous neuropathy lesions, as well as in other higher radial neuropathies that are purely demyelinating. The superficial radial sensory nerve is easy to palpate over the extensor tendons. The superficial radial nerve is stimulated 10 cm proximal to G1 over the radial bone. If there has been secondary axonal loss, the response will be diminished in amplitude. Similar to motor studies, it is often useful to compare the response with the contralateral asymptomatic side. If the pathology is one of pure or predominant proximal demyelination, a very interesting phenomenon occurs. This unusual finding (a normal sensory response in the distribution of cutaneous numbness) can occur in only one of three situations: (1) a hyperacute axonal loss lesion (before wallerian degeneration has occurred), (2) a lesion proximal to the dorsal root ganglion, or (3) a lesion caused by proximal demyelination. Thus, in cases of radial neuropathy at the spiral groove or axilla, a pure proximal demyelinating lesion will result in a normal superficial radial sensory potential, despite sensory loss on clinical examination. Note that if the clinical examination suggests weakness beyond the radial distribution, investigation for a more widespread neuropathy is indicated, especially a search for conduction blocks along other motor nerves, which may indicate multifocal motor neuropathy with conduction block (see Chapter 29). At least one radial-innervated muscle proximal to the bifurcation of the main radial nerve near the elbow but distal to the spiral groove. The anconeus can essentially be thought of as an extension of the medial head of the triceps. Thus, in severe or complete radial neuropathies at the spiral groove, every radial-innervated muscle in the forearm (which includes every wrist and finger extensor), as well as the supinator and brachioradialis, may be completely denervated, and only the anconeus will be normal. Thus, these muscles are very helpful in determining if the lesion is at the level of the posterior interosseous nerve, oraboveit,intheregionoftheelbow. Second, much of supination is subserved by the biceps muscle (the primary function of the biceps is elbow flexion; its secondary function is forearm supination). Third, the supinator and its relationship to the radial nerve are somewhat akin to that of the pronator teres and the median nerve: the deep branch of the radial nerve runs through the supinator muscle at which point it is known as the posterior interosseousnerve. However,thebranchorbranches supplying the supinator originate from the deep radial motor branch before it enters under the Arcade of Frohse. Lesions at that location may or may not affect the innervation to the supinator (again, akin to the pronator teres being spared in some cases of pronator syndrome). Because of these limitations, the supinator is best avoided, especially since there are other muscles (especially the brachioradialis and long head of the extensor carpi radialis) that can be more easily sampled that are below the spiral groove but proximal to the posterior interosseous nerve. If the lesion is at the axilla, the above muscles, as well as the triceps and anconeus, will be involved. A proximal lesion of the posterior cord will show additional abnormalities, including the deltoid (axillary nerve) and latissimus dorsi (thoracodorsal nerve). A C7 radiculopathy will show abnormalities of the cervical paraspinal muscles and radial-innervated C7 muscles. As the radial nerve runs in close proximity to the humerus, it can commonly be injured from a fracture or as a complication of the subsequent surgery, including impingement by surgical hardware. One potential entrapment site is the space between the humerus and the edge of a surgical plate (red arrow). Thus, these muscles are very helpful in determining if the lesion is at the level of the posterior interosseous nerve, or proximal to it, in the main radial nerve in the region of the elbow. This is especially important because if the needle is mistakenly placed in the short head of the extensor carpi radialis (also known as the extensor carpi radialis brevis), and found to be abnormal, the mistaken impression may arise of a lesion in the main radial nerve at or proximal to the elbow, whereas the lesion may actually be more distal, in the deep radial motor branch. This is because the short head of the extensor carpi radialis has several common anatomic variants: it can arise from the main radial nerve in the elbow as well as from the deep radial motor branch, and rarely from the proximal superficial radial nerve. One can see that if the short head of the extensor carpi radialis in this case is supplied by the deep radial motor branch rather than the main radial nerve, the mistaken impression of a lesion of the main radial nerve could be made. Because of the anatomic variations of the nerve supply to the extensor carpi radialis brevis, abnormalities in this muscle cannot differentiate between lesions of the main radial nerve in the elbow and the deep radial motor branch. Thus, although the long head of the extensor carpi radialis can be routinely sampled, of the available muscles that can be sampled that are below the spiral groove but proximal to the bifurcation of the radial nerve just distal to the elbow, the brachioradialis is the easiest and has the fewest potential problems. Although the most common radial neuropathy occurs from external compression at the spiral groove, there are other internal structural lesions that can affect the radial nerve at various sites along its course. In addition, fracture of the humerus and subsequent surgical open reduction and internal fixation can injure the radial nerve. Neuromuscular ultrasound also plays an especially important role in the evaluation of lesions of the deep branch of the radial nerve and the posterior interosseous nerve. Third, when they do occur, they are often caused by unusual structural lesions and, at other times, occur as part of neuralgic amyotrophy (see Chapter 33). For all of these reasons, ultrasound is often the key test that can determine whether an entrapment is actually present and, if it is, what is causing it. To visualize the radial nerve, the patient is asked to lie supine with the elbow slightly bent and the hand pronated. The probe is placed in the short axis in the groove between the biceps and brachioradialis. At this location, the radial nerve is easily seen in the fascial plane between the brachioradialis above and the brachialis muscle below. The nerve first runs in muscle, but as the probe approaches the mid-arm, the bony shadow of the humerus will appear. Moving more proximally and slightly laterally, the radial nerve will come into contact with the surface of the humerus. The nerve then runs posterior, adjacent to the spiral groove, before traveling deep to the triceps in the upper arm. Once the radial nerve is followed to the spiral groove, the probe is returned to the starting position in the groove between the brachioradialis and brachialis muscle and then moved distally. The supinator has a characteristic arched shape and pattern as it surrounds the radius. However,asthenerveentersthesupinator,thereisoftena change in caliber: the nerve diameter decreases slightly while its width increases slightly. Distal to the supinator, the posterior interosseous nerve runs between the deep and superficial layer of the forearm extensor muscles. As the radial nerve is about to bifurcate into its superficial and deep branches, it will often form two distinct fascicles within the nerve, which have a "snake eyes" or "spectacles" appearance. As the radial nerve is about to bifurcate into its superficial and deep branches, it will often form two distinct fascicles within the nerve that have a "snake eyes" or "spectacles" appearance. Right, Same image with the radius in green, the posterior interosseous nerve in yellow, and the two heads of the supinator muscle in red. When the nerve is between the two heads of the supinator, it is most often circular or oval in shape. Bottom, Same image with the posterior interosseous nerve divided into several branches in yellow, and the two heads of the supinator muscle in red. In addition to being a single circular or oval fascicle, the posterior interosseous nerve may also divide into two, three, or four fascicles aligned in a row between the two heads of the supinator. Bottom, Same image with the posterior interosseous nerve in yellow, posterior interosseous artery in bright red, superficial extensors in dark red, and deep extensors in light blue. Distal to the supinator, the posterior interosseous nerve (white arrow) runs between the deep and superficial layers of the forearm extensor muscles. The nerve is often difficult to visualize but accompanies the posterior interosseous artery, which helps locate the nerve. Back at the elbow, the superficial branch can usually be followed down the forearm. As it approaches the wrist, the brachioradialis transitions from muscle to tendon. Near that point, the superficial radial nerve moves more superficially between the brachioradialis tendon above and the extensor carpi radialis longus below. Other lesions of the radial nerve in the upper arm are unusual, unless there has been a fracture, with or without surgical repair. As noted earlier, there are five potential sites of compression of the deep radial motor branch/posterior interosseous nerve, although some sites are more common than others. These include, from proximal to distal: (1) the medial proximal edge of the extensor carpi radialis brevis muscle; (2) the fibrous tissue anterior to the radiocapitellar joint between the brachialis andbrachioradialismuscles;(3)the"LeashofHenry";(4) the Arcade of Frohse; and (5) the distal edge of the supinator muscle. Top, Native images, Bottom, Same images with the superficial radial nerve in yellow, the brachioradialis in red, radius in green and the cephalic vein in blue. The superficial radial nerve is quite small and difficult to appreciate on still images. However, when moving the probe up and down the forearm, the nerve becomes more conspicuous. It first runs under the brachioradialis and later becomes more superficial under the brachioradialis tendon and eventually subcutaneous near the wrist. Note how the nerve enlarges and is hypoechoic with loss of the normal fascicular structure at the spiral groove. Left, Nerve conduction study recording the extensor indicis proprius in a patient with a complete wrist and figure drop. Note the complete conduction block between the below- and above-spiral groove sites.

Healthy cell transplants are harvested from the individual client (autologous) allergy medicine that won't make me sleepy cheap nasonex nasal spray 18gm with mastercard, from an identical twin (syngeneic) allergy treatment tulsa purchase cheapest nasonex nasal spray and nasonex nasal spray, from a sibling or parent allergy testing antibiotics generic nasonex nasal spray 18gm with amex, or from an unrelated person (allogeneic) allergy forecast germany buy cheap nasonex nasal spray line. These cells are then transplanted into the recipient much like a blood transfusion allergy symptoms 7 weeks best order nasonex nasal spray. The goal of transplantation therapy is to restore stem cells destroyed by high doses of chemotherapy or radiation allergy medicine in pregnancy order nasonex nasal spray 18 gm visa. The transplanted cells travel to the bone marrow where they begin to produce new blood cells that ultimately replace the cancer cells. To prevent this kind of reaction, recipients are often given medications to suppress their immune system. Researchers had known for some time that mass doses of intravenous viral therapy can kill cancer in mice, but this was the first time the therapy was used on a human. Time and continued research will determine the lasting effects of such a revolutionary approach to cancer treatment. He was able to check off at least one event on his "bucket list"-to go into a boxing ring to spar with a professional. Measles Vaccine for Cancer Treatment Research is currently under way investigating the use of the measles vaccine to treat cancers of the blood. The Mayo Clinic injected a patient, who had run out of all options for her cancer treatment, with enough measles vaccine to inoculate 10 million people. Integrative and Complementary Therapy Most individuals diagnosed with cancer have considered or participated in some form of complementary medicine therapy, and they spend billions of dollars 92 Diseases of the Human Body per year, mostly out-of-pocket, for integrative and complementary medical treatment. In some circles, the debate rages on, with traditional therapies on one side and complementary on another. Increased benefit may be achieved if persons with cancer carefully consider both traditional or conventional treatments and complementary treatment therapies. Integrative practitioners recognize all the major forms of conventional cancer treatment and understand the wisdom of each. Integrative oncology moves into another arena, however, in that it includes evidence-based therapy that can offer prevention, support, and antineoplastic treatment. Generally, there is no debate regarding prevention of cancers; both traditional and integrative practitioners agree on all the main preventive factors. Also, there is little disagreement in the "supportive" aspect for persons with cancer. However, integrative practitioners usually pay closer attention to that treatment area than do traditional practitioners, who often rush to aggressively treat the cancer before it has an opportunity to metastasize. When chemotherapy and/or radiation is deemed necessary, complementary therapies can, in some cases, reduce many side effects or enhance the effectiveness of chemotherapy and radiation. Proponents of complementary therapies consider that cancer is a manifestation of an unhealthy body whose defenses are so seriously out of balance that they can no longer destroy cells that turn cancerous. These therapies may include treatments that rely on biopharmaceutical, immune enhancement, metabolic, nutritional, and herbal nontoxic methods. Also, eating a macrobiotic diet (mostly vegetables and whole grains), drinking green tea, and using more soy products in the diet appear to assist in enabling the body to destroy cancer cells. Some complementary remedies may actually make cancer worse if not used properly, just as conventional methods can be so toxic that a person succumbs to the treatment rather than to the disease itself. Any complementary therapies should become a part of a total cancer treatment program that is guided and monitored by a qualified practitioner experienced in integrative medicine and treatment. However, the following seven steps are consistent in nearly all prevention measures. Smoking cigarettes, cigars, pipes, chewing tobacco, inhaling chewing tobacco or snuff, and inhaling secondhand smoke puts you at risk for a number of different cancers. A diet that includes vegetables, fruits, whole grains, and legumes and that limits fat intake helps to reduce cancer risk. Exercise is helpful in prevention of obesity and may also lower risks of breast, colon, prostate, and uterine cancers. Regular screening should be done for the skin, mouth, colon, rectum, prostate, testes, breast, and cervix. Department of Health and Human Services recommend a mammogram every 1 to 2 years for women older than age 40. Also, the Papanicolaou test should be performed on women (3 years after becoming sexually active or by age 21) at regular intervals-every 3 years for women ages 21 to 65. A rectal examination should be part of every medical checkup for men and women, and stool samples should be examined for blood, which may be an indication of colon cancer. It can strike with or without warning and has been a recognized disease for more than 100 years. If the spread is not controlled or checked, cancer can result in death; however, many cancers can be cured if detected and treated promptly. He saw his doctor for what he thought was a pulled muscle in his side, a nagging cough, and feeling tired all the time. Juan had a radical nephrectomy with removal of surrounding lymph nodes and the adrenal gland. Which of the following is treatment for cancers of leukemias, lymphomas, and some other tumors Hormonal therapy Substances that can increase the risk of cancer development Estimates the extent to which a tumor has spread Removes much of tumor without destroying nearby tissues Arise from supportive and connective tissue Removes skin cancer one layer at a time Carcinoma in situ Indicates distant metastasis 3. Where have stem cell and bone marrow transplants been most effective in treatment What are the substances in the blood, urine, and tissues of individuals with cancer that are used in diagnosis and prediction of certain therapies Can you name the surgery for cancer that is done to sustain an individual or alleviate pain Discuss the reasons to include an integrated medicine approach to cancer treatment. Everything was progressing normally and they were delighted when ultrasound showed they would have a son. The months flew by, the nursery was ready, and when labor began, they had no fears. In the hospital, Melanie struggled for 12 hours in labor before Josh was born close to 2:00 a. One of the nurses asked for the name of their pediatrician and then said they would take Josh to be weighed and checked. Hank and Melanie were a little concerned; they thought they would be able to hold him longer. Children with congenital abnormalities may require more medical care, more frequent hospitalizations, and increased educational services than children with no abnormalities. The most common congenital abnormalities affect the cardiovascular system, followed by neural tube defects, and are identified first in this chapter. Acyanotic defects are those in which there is no mixing of poorly oxygenated blood with the blood reentering the systemic circulation. Cyanotic defects are those in which poorly oxygenated blood mixes with the blood reentering the systemic circulation. Acyanotic Defects Acyanotic defects occur when the blood flows from the left side of the heart to the right side of the heart due to a hole in the interventricular septum. The extent of the opening may vary from the size of a pin to a complete absence of the ventricular septum, creating one common ventricle. Blood from the left ventricle flows back into the right ventricle, causing too much blood to be pumped to the lungs. This defect typically accompanies other congenital anomalies, especially Down syndrome, renal defects, or other cardiac defects. Here, the term congenital disease refers to problems that are present at birth even if they do not exhibit until sometime later. Major abnormalities affect the way a person looks and generally require medical and/or surgical treatment. Congenital abnormalities or birth defects may have genetic causes, may be caused by exposure to some agent or teratogen during pregnancy that causes malformation, or may result from a combination of the two. The most common teratogens are infectious diseases, physical agents such as radiation, drugs and chemicals, and maternal issues such as diabetes. Congenital defects usually occur during the first 3 months of pregnancy, many in the first 3 to 4 weeks of pregnancy before a woman suspects she is pregnant. Some abnormalities may be detected at birth; others are not apparent until later in infancy or childhood. There are more than 3,000 possible abnormalities, including 21 that are considered major. This backflow causes an extra volume of blood to be pumped into the lungs by the right ventricle, creating lung congestion. Consequently, blood pressure is increased proximal to the defect and decreased distal to it. During the prenatal period, much of the fetal circulation bypasses the lungs through this blood vessel, which connects the pulmonary artery to the aorta. When this fetal structure fails to close after birth, blood from the aorta flows back into the pulmonary artery. This defect is common in premature infants and puts a strain on the heart, causing tachypnea, or fast breathing. Cyanotic Defects Cyanotic defects cause the oxygen-rich blood and the oxygen-poor blood to mix, allowing less oxygen-rich blood to reach the body tissues. The result is two noncommunicating circulatory systems-one circulating blood in a closed loop between the heart and lungs and the other between the heart and systemic circulation. In this condition, the aorta is narrowed or constricted, obstructing blood flow to the lower part of the body and increasing blood pressure above the constriction. Usually there are no symptoms at birth, but they can develop as early as the first week of life. If severe symptoms of high blood pressure and congestive heart failure develop, surgery may be considered. Prior to birth, there is an open passageway between the two blood vessels that closes soon after birth. Etiology the etiology of congenital heart defects is mostly unknown, but there may be a genetic link. Predisposing factors may include maternal infections, use of certain drugs during gestation, diabetes, alcoholism, and poor maternal nutrition. In roughly 85% of cases, however, there is no one identifiable cause of a congenital heart defect. The abnormalities are thought to be multifactorial-both genetic and environmental. There may be signs of rapid, heavy breathing; poor feeding; poor weight gain; and sweating. The classic clinical feature is a crescendo-decrescendo type of systolic ejection murmur. An infant may exhibit dyspnea, pulmonary edema, tachycardia (an abnormally rapid heartbeat), and failure to thrive. Symptoms appearing after adolescence may include dyspnea, claudication (lameness), headache, epistaxis (nosebleed), and hypertension. The infant may exhibit other signs of poor oxygenation, such as increasing dyspnea on exertion, diminished exercise tolerance, and delayed physical growth and development. Signs of congestive heart failure and cardiomegaly (an increase in the volume of the heart or the size of the heart muscle tissue) follow. This condition is characterized by four defects: (1) An abnormal opening or ventricular septal defect that allows blood to pass from the right ventricle to the left ventricle without going through the lungs. With this congenital defect, the positions of the pulmonary artery and the aorta are reversed, thus the aorta originates from the right ventricle, so most of the blood returning to the heart from the body is pumped back out without first going to the lungs, and the pulmonary artery originates from the left ventricle, so that most of the blood returning from the lungs goes back to the lungs again. Diagnostic Procedures Signs and symptoms often point to a diagnosis, but a history and physical examination are essential and may be all that are necessary to diagnose some congenital heart abnormalities. Laboratory studies may be ordered to determine the degree of cyanosis and to detect possible acidosis. Treatment Some congenital heart defects require no treatment because there is spontaneous closure of the defects, or some medications may be effective in closing defects. Surgery may include closing holes in the heart with patches or stitches, repairing or replacing heart valves, or widening arteries or openings to heart valves. When the defect is complex, however, more than one surgical procedure may be required. Some surgical procedures may be delayed until the child is old enough to better withstand the surgery. A needle puncture is made in the skin to insert a catheter into a vein or artery to repair some defects. Because this procedure is much easier than surgery on an individual with a birth defect, it is the preferred treatment when possible. Reassurance is important and should include explanations to the parents and caregivers of any procedures to be performed. Prognosis the prognosis is dependent on the type of defect, its location, and its severity. In tricuspid atresia, there is no tricuspid valve; therefore, no blood flows from the right atrium to the right ventricle. Tricuspid atresia defect is characterized by a small right ventricle, a large left ventricle, diminished pulmonary circulation, and cyanosis. A surgical shunting procedure is often necessary to increase the blood flow to the lungs. It is a hereditary, chronic anemia in which abnormal sickle- or crescent-shaped red blood cells are present. These abnormally shaped red blood cells tend to clump together within capillaries, impairing circulation, damaging blood vessels, and causing chronic organ damage.

These layers of connective tissue (pleura and peritoneum) cover the outer and inner borders of the diaphragm and are key in identifying it with ultrasound allergy treatment providers generic nasonex nasal spray 18 gm overnight delivery. Note with the probe placed between two ribs on the right allergy medicine you can take with alcohol generic 18gm nasonex nasal spray otc, the following tissues are seen from superficial to deep: skin allergy treatment vitamin c purchase nasonex nasal spray 18 gm on-line, subcutaneous tissue allergy forecast in san antonio purchase 18 gm nasonex nasal spray mastercard, intercostal muscles allergy center buy nasonex nasal spray 18gm low cost, pleural lining allergy shots effective for cat allergies buy nasonex nasal spray without prescription, diaphragm, peritoneal lining, and liver. Anythicknessbelowthis,especiallywhenassociatedwith increased echogenicity, indicates atrophy and dysfunction of the diaphragm. Thepatientisthenasked to take deep breaths in and out while the diaphragm is visualized. This is a very good objective test of diaphragmatic function, provided the patient can cooperate. When one visualizes the diaphragm at the anterior axillary line, the liver is below the diaphragm on the right, and the spleen is below the diaphragm on the left. If the diaphragm dome moves down lower than the level of the probe, the diaphragm will disappear and will be replaced by homogeneous lung tissue. With the probe placed in this position, on the right side, the liver acts as an acoustic window. Beginning on the right side, when the probe is slightly rotated cranially, medially and posteriorly, a bright hyperechoic line is seen at the posterior side of the liver. The index line of the M-mode is placed over the bright hyperechoic line of the diaphragm. Left, At end expiration, the diaphragm is relaxed, dome shaped, and higher in the chest. Right, During inspiration, the zone of apposition narrows as the dome shaped diaphragm descends and flattens. Right, Same image with the diaphragm in red, intercostal muscles in purple, and bone echoes of the two ribs in green. Sagittal oblique view across the interspace between the seventh and eighth ribs at the anterior axillary line. In many patients, there may be a thin piece of hyperechoic connective tissue running in the center of the diaphragm (light blue). The "thickening ratio" is calculated by comparing the thickness of the diaphragm at end inspiration with end expiration. However, the left side is frequently more challenging because there is no liver to act as an acoustic window. On the left side, the spleen is used as an acoustic window, but the spleen is smaller and may not extend to the anterior axillary line. When both sides are finished, the excursions are measured and compared from side to side. Normally, the left side moves more than the right side because the liver offers more resistance to movement on the right. Left, Sagittal oblique view across the interspace between the seventh and eighth ribs at the anterior axillary line, native images. The top image is at the start of inspiration; the bottom image is at full inspiration. During deep inspiration, lung tissue can descend and "peel back" the diaphragm at some intercostal spaces. If the ultrasound probe is at a level where the diaphragm dome moves lower than the probe, the diaphragm will disappear and will be replaced by homogeneous lung tissue. With the probe placed subcostally at the midclavicular line, the posterior diaphragm is seen as a bright line adjacent to the liver (red arrow) on B-mode. An index line (yellow arrow) is then placed so it intersects with the echo from the diaphragm. This is the line of ultrasound that is recorded over time in the M-mode image below. The normal range of excursion between inspiration and expiration is greater than 1. Comparing side to side, the left should normally move more than the right, but not by more than 50%ontheleftcomparedtotheright. Movementmore than 50% on the left compared with the right implies some dysfunction on the right. Likewise, if all breaths are delivered by the ventilator, these parameters cannot be assessed. M-mode diaphragmatic studies can also be done during phrenic nerve conduction studies. Diaphragmatic excursion was actually a superior method of assessing phrenic nerve function when compared with phrenic nerve conduction studies. This data strongly suggest that ultrasound may be preferable to phrenic nerve conduction studies to optimally assess phrenic nerve function. It is true that the diaphragm can be a very useful muscle to study in patients with neuromuscular weakness. Ultrasound not only visualizes the diaphragm but also confirms that during inspiration the lung shadow does not appear. More importantly, it can measure the distance to the diaphragm from the skinsurface. Ultrasound not only visualizes the diaphragm, but also confirms that during inspiration the lung shadow does not appear. More importantly, it can measure the distance between the skin surface and the diaphragm. Thus, if the distance from the skin to the diaphragm is 20 mm, and a 25-mm-length needle is used, one can properly approximate how far the needle needs to go in to reach the diaphragm. Direct ultrasound guidance can be done with either the "in-plane" or "out-of-plane" technique. Right, Using the in-plane technique, the needle is inserted at a very shallow angle at the middle of the end of the probe and kept parallel to the length of the probe. With this technique, the needle can be seen at all times as it passes through the subcutaneous tissue, underlying muscle, and eventually to the target of interest. Left, Using the out-of-plane technique, the needle is inserted at a much more acute angle just adjacent to the middle of the probe, aimed toward the probe. However, as the needle is advanced, that same bright hyperechoic spot remains the same. To do this technique correctly, one needs to identify the first time that the needle tip is seen, and then ever so slightly move the probe away from the needle, and insert the needle further until the needle tip is again first seen. This technique is known as "walking down" the needle until it reaches the area of interest andensuringsafety. This indication is not unique to the diaphragm and can be done in the study of other muscles. In this situation, ultrasound is used simultaneously as the needle is placed into the muscle. This technique requires a longer needle and insertion of the needle at a much shallower angle than usual. With the out-of-plane technique, the needle is inserted at a much more acute angle, just adjacent to the middle of the probe aimed toward the probe. The tip of the needle will be recognized as a bright hyperechoic spot on ultrasound. One cannot differentiate between the tip of the needle and the shaft of the needle. To perform this technique correctly, one needs to identify the first time the needle tip is seen, and then ever so slightly move the probe away from the needle, and insert the needle a bit further until the needle tip is again first seen. This technique is known as "walking down" the needle until it reachestheareaofinterest. The most common is reverberation artifact for the in-plane technique and comet tail artifact for the out-of-plane technique (see Chapter17). Patients with chronic unilateral phrenic palsies have atrophic and hyperechoic diaphragms on the affected side, which will not increase in thickness with inspiration. In cases of myopathy affecting respiratory function, both sides of the diaphragm may show atrophy and hyperechoic changes. During mechanical ventilation in patients without any neuromuscular condition, the diaphragm has been shown to begin to atrophy within a few days. Two-dimensional ultrasound imaging of the diaphragm: quantitative values in normal subjects. Visualization of the diaphragm muscle with ultrasound improves diagnostic accuracy of phrenic nerve conduction studies. Early development of critical illness myopathy and neuropathy in patients with severe sepsis. Acutemyopathy of intensive care: clinical, electromyographic, and pathologic aspects. Acutemyopathyand neuropathy in status asthmaticus: case report and literature review. Persistent paralysis in critically ill patients after long term administration of vecuronium. Critical illness polyneuropathy: a complication of sepsis and multiple organ failure. Indeed, there are a large number of neuromuscular disorders that present in the pediatric age group. A complete discussion of pediatric neuromuscular disorders and electrodiagnosis is beyond the scope and purpose of this chapter (see Suggested Readings). These differences include both physiologic and nonphysiologic factors that may vary considerably between age groups. In addition, neuromuscular ultrasound can potentially be a very useful adjunct in assessing children with certain suspected neuromuscular disorders. In many cases, it may not be clear from the symptoms and signs whether the etiology is central or peripheral. One of the best examples of this predicament is that of the floppy infant, in whom the differential diagnosis includes the entire length of the neuraxis, from brain to muscle. This is especially important when interpreting conduction velocities and differentiating a normal conduction velocity from axonal loss or demyelination. In most cases, this is not because infants and young children have demyelinated nerves; rather, they have nerves that have yet to be myelinated in the first place. The process of myelination is age dependent, beginning in utero, with nerve conduction velocities in full-term infants approximately half that of adult normal values. One interesting aspect of myelin maturation is often observed during nerve conduction studies in the pediatric population. For example, entrapment neuropathies are very common in adults but are extremely rare in children. Electrophysiologic correlates of peripheral nervous system maturation in infancy and childhood. Similarly, different fibers in the peripheral nervous system myelinate at different times as well. This bifid morphology is due to some fibers having already been fully myelinated (the first peak), whereas others have not and trail behind. Eventually, as the fibers in the second peak fully myelinate, the second peak moves to the left and merges with the first peak. At that point, the second peak will move to the left and merge with the first peak to form a larger sensory response. Although the F response often is thought of as evaluating the proximal nerve segments, it assesses the entire length of the nerve, from the stimulation point to the spinal cord and back, and then past the stimulation point to the muscle. Thus, the F response latency depends not only on the conduction velocity and distal latency but also on the length of the limb. Because infants and children have slower conduction velocities than adults, one would expect the F responses to be very long. However, counterbalancing this is the very short limb length of a child compared with an adult. Thus, there are two opposing influences on the F response in children: limb length and conduction velocity. It is no surprise that the physical size of a motor unit of a newborn is much smaller than that of an adult. Transverse motor unit territory increases greatly with age, doubling from birth to adulthood, mostly because of the increase in individual muscle fiber size. The first important issue is measurement of distances and its relationship to technical errors. When short distances are used, a small error in measurement creates a much larger error in computed conduction velocities than when longer distances are used. For instance, in an adult, if the distance between the wrist and the elbow is measured at 20 cm but is off by 1 cm. Second, smaller electrodes often are needed in infants and young children because their limbs and muscles are so small. Standard 10- m disc electrodes often will suffice for most ages, m except for newborns, in whom smaller electrodes generally are needed.

Dorsal Ulnar Cutaneous Sensory Study Recording the dorsal ulnar cutaneous sensory nerve can be a useful technique to perform in patients with suspected ulnar neuropathy allergy testing infants discount nasonex nasal spray 18gm without a prescription. The active electrode (G1) is placed over the muscle belly allergy medicine you rub on your nose 18 gm nasonex nasal spray with visa, and the reference electrode (G2) is placed over the metacarpophalangeal joint of the thumb allergy forecast flagstaff az discount nasonex nasal spray 18gm with amex. Recording the first dorsal interosseous is helpful in ulnar neuropathy at the wrist and in some cases of ulnar neuropathy at the elbow allergy forecast ireland cheap nasonex nasal spray 18gm with mastercard. A normal antidromic response is greater than 8 V allergy symptoms 7-8 order nasonex nasal spray 18gm otc, but allergy treatment kolkata buy line nasonex nasal spray, as in other uncommonly performed sensory nerve conduction studies, comparison with the contralateral asymptomatic side frequently is helpful. Any potential that is less than 50% that of the contralateral asymptomatic side likely is abnormal. Thus, in cases where the dorsal ulnar cutaneous sensory response is absent, it is prudent to stimulate the superficial radial sensory nerve along the lateral radius with the recording electrodes in place for the dorsal ulnar cutaneous sensory study to ensure that this very rare anomalous innervation is not present. If the reference electrode is placed on the metacarpophalangeal joint of the index finger, an initial positive deflection often will be seen, which complicates latency measurements. If the lesion is pure demyelination at the elbow, both distal sensory responses will be normal. This finding is thought to be due to preferential fascicular sparing of the dorsal ulnar cutaneous sensory fibers at the elbow. Studies of the microanatomy of the fascicle that forms the dorsal ulnar cutaneous sensory branch have shown that it commonly separates from the main ulnar trunk above the elbow and effectively travels as a separate nerve next to the ulnar nerve in the forearm. Normal sensory responses decrease markedly in amplitude and area, whereas their duration increases, at more proximal stimulation sites because of the normal processes of temporal dispersion and phase cancellation. For this reason, proximal demyelinating lesions in sensory fibers can be detected only by conduction velocity slowing and not by drop in amplitude or area. With the hand in a pronated position, recording electrodes are placed in the dorsal web space between the fourth and fifth fingers. Both assume lesions that involve axonal loss and that there is no anomalous innervation of the dorsal ulnar cutaneous sensory nerve. However, significant exceptions to these classic patterns may occur: if (1) the ulnar neuropathy at the elbow is purely demyelinating or (2) there is an ulnar neuropathy at the wrist that spares the sensory branch. Nerve Conduction Study Pitfalls When performing routine ulnar nerve conduction studies, one must keep in mind several important technical factors: 1. When stimulating at the below-elbow site, the stimulator must be located 3 cm distal to the groove to ensure that the stimulation point is distal to the cubital tunnel. In this situation, one could see a drop in amplitude between the below-elbow and aboveelbow stimulation sites. Thus, the optimal position to stimulate the below-elbow site is 3 cm distal to the medial epicondyle, not less, not more. The distance from the below-elbow site to the aboveelbow site ideally should be 10 cm. If shorter distances are used, slight errors in measurement may create large differences in calculated conduction velocities. If longer distances are used, a longer length of normal nerve may dilute any conduction velocity slowing across the elbow, yielding normal or equivocal results. The optimal site for the below-elbow stimulation site is 3 cm distal to the medial epicondyle. The most common cause of drop in amplitude between the wrist and below-elbow sites during routine ulnar motor conduction studies is not true conduction block but a Martin-Gruber anastomosis. Conduction block of the ulnar nerve in the forearm should never be diagnosed unless the median nerve has been stimulated at the wrist and antecubital fossa to exclude a Martin-Gruber anastomosis. This underscores that the correct site to stimulate the ulnar nerve below the elbow is 3 cm distal to the medial epicondyle. Rarely, flexing the elbow causes the ulnar nerve to sublux out of the groove medially over the medial epicondyle. Martin-Gruber anastomosis with anomalous superficial radial innervation to ulnar dorsum of hand: a pitfall when common variants coexist. It is important to emphasize that a subluxed ulnar nerve interferes with determination of the true conduction velocity across the elbow, but not conduction block across the elbow. Median- and radialinnervated C8 muscles are screened to rule out evidence of a C8 radiculopathy or lower trunk brachial plexopathy. If a cervical radiculopathy is suggested based on clinical history, then sampling the cervical paraspinal muscles is also indicated. In this situation, neuromuscular ultrasound is particularly helpful (see the following section). Examination of the medial antebrachial cutaneous sensory nerve, which comes directly off the medial cord of the brachial plexus, may help identify a lower brachial plexus lesion. Ultrasound is able to visualize the ulnar nerve throughout its course in the upper extremity, from the wrist to the axilla. The nerve is fairly superficial at all locations and is easily imaged with a high-frequency probe. Not only can ultrasound localize the site of the ulnar neuropathy when it occurs at the elbow, but it can also be precise in differentiating between a lesion at the retrocondylar groove versus the cubital tunnel proper. Like other entrapment neuropathies, ultrasound can yield key diagnostic information about nerve entrapment and structural lesions affecting the ulnar nerve (Table 22. In the vast majority of individuals, the ulnar nerve runs in a curved pattern (green line) through the ulnar groove between the medial epicondyle (upper black dot) and the olecranon (lower black dot). However, in some individuals, when the elbow is flexed, the ulnar nerve will sublux out of the groove medially over the medial epicondyle (red line). In these cases, the measured distance (green line) will overestimate the true distance (red line), which then results in an overestimate of the ulnar conduction velocity across the elbow. Accordingly, in some cases of true ulnar neuropathy at the elbow, this could result in a false-negative study. Ulnar muscle distal to the wrist (first dorsal interosseous or abductor digiti minimi) 2. The patient may note the snap of the ulnar nerve coming out of the groove during certain movements and, in the case of the ulnar nerve and the triceps, a double snap. When visualizing the ulnar nerve, the patient lies supine on the examining table, with the arm initially extended. The probe is first placed in short axis over the median nerve at the distal wrist crease at the standard starting median nerve location. Once the median nerve is well identified, the probe is slowly moved toward the ulnar side of the wrist looking for a prominent hypoechoic structure, which is the ulnar artery. Next, the probe is slowly moved proximally over the forearm while following the ulnar nerve. The ulnar artery runs laterally to eventually join the median nerve in the forearm. The probe is then moved proximally while following the ulnar nerve as it runs first through the cubital tunnel and then through the retro-condylar groove. We prefer to visualize the nerve in the retrocondylar groove with the elbow in the extended position, with the arm supinated. A generous amount of gel is needed when the probe is placed on a line connecting the medial epicondyle and the olecranon. The ulnar nerve runs in between, often very close to the posterior border of the medial epicondyle. In addition, at this location, very gentle probe pressure is maintained while keeping the nerve in view as one passively flexes the elbow. One looks to see if the ulnar nerve subluxes over the medial epicondyle, and in some cases may frankly dislocate to the other side of the medial epicondyle. One can repeat this maneuver several times to determine if the nerve subluxes over the medial epicondyle. Presumably, the repetitive friction over the medial epicondyle results in injury to the ulnar nerve. At the elbow, one also inspects for other structural lesions, especially ganglion cysts and anomalous muscles. There are several structural abnormalities to specifically look for when assessing the ulnar nerve at the elbow. Bottom, Same images with the ulnar nerve in yellow, triceps in red, and bone shadow of the medial epicondyle in green. Note that with the elbow in the flexed position, the ulnar nerve along with the triceps sublux out of the groove over the medial epicondyle. In the forearm, the ulnar artery and nerve run together, first under the tendon and then the muscle of the flexor carpi ulnaris. Right, Same images with the ulnar nerve in yellow and medial epicondyle and olecranon in green. In the retrocondylar groove, the ulnar nerve is located very close to the posterior border of medial epicondyle. If the callus is near the ulnar nerve, it can erode into the nerve, especially if the nerve is in a location where it normally slides over the bone. Bottom, Same image with the ulnar nerve in yellow, medial epicondyle and olecranon in green, and an accessory epitrochlearis muscle in red. This is an anomalous muscle that runs from the medial epicondyle to the olecranon and in some cases can directly compress the underling ulnar nerve. These cysts arise from the nearby elbow joint and, if they are large enough, can impinge on the ulnar nerve. Right, Same image with the ulnar nerve in yellow, triceps in red, and humerus in green. At this location, the ulnar nerve is very near to the surface, just under the skin and subcutaneous tissue, and superficial to the triceps muscle. Right, Same images with the ulnar nerve in yellow and flexor carpi ulnaris in red. In addition, the posterior ulnar recurrent artery often accompanies the ulnar nerve posterior to the medial epicondyle. From the groove, the probe should next be moved to the upper arm while following the ulnar nerve. The reason that the ulnar nerve is so easy to stimulate with a low stimulus current at the above the elbow site on nerve conduction studies is that it is so superficial at this location. Next, the probe is returned to the elbow to assess the ulnar nerve at the cubital tunnel. If the ulnar nerve is enlarged at any location, especially at the cubital tunnel or the retrocondylar groove, long-axis imaging should also be performed. Left, Adjacent short axis images of the ulnar nerve in the cubital tunnel, native images. In this case, the ulnar nerve is enlarged and hypoechoic with an abnormal fascicular architecture. There is a large anechoic circular lesion abutting and displacing the ulnar nerve. However, as noted earlier, the normal ulnar nerve is often somewhat hypoechoic at the retrocondylar groove. Also, as noted previously, assessing mobility is important to look for subluxation and dislocation. Bottom, Same image with the ulnar nerve in yellow and flexor carpi ulnaris in red. Note the enlarged and hypoechoic ulnar nerve with an abnormal fascicular architecture. The swelling ratio of the elbow to mid-forearm and elbow to mid-arm should not exceed 1. Thus, any ulnar nerve that is greater than 50% larger at the elbow than the mid-forearm or the mid-arm is abnormal. The swelling ratio is especially helpful in patients who have borderline enlarged nerves at baseline. Similar to other entrapment neuropathies, one can also look at the pattern of denervation atrophy to help determine a localization. The flexor pollicis brevis lies adjacent to the bony shadow of the first metacarpal and has two heads. In most individuals, the superficial head (yellow arrow) is supplied by the median nerve and the deep head (green arrow) is supplied by the ulnar nerve. In cases of ulnar neuropathy associated with denervation, the superficial head of the flexor pollicis brevis will be normal (yellow arrow) while the deep head will be hyperechoic (green arrow). The flexor pollicis brevis has two heads, and in most individuals, the superficial head is supplied by the median nerve and the deep head is supplied by the ulnar nerve. In cases of ulnar neuropathy associated with denervation, the superficial head of the flexor pollicis brevis will be normal, while the deep head will demonstrate a hyperechoic muscle. In all cases, ultrasound was able to determine the localization as well as add etiologic information. In 10 patients, ultrasound localized the lesion to either the cubital tunnel, the retrocondylar groove, or both. In the other two, one showed a lesion in the distal forearm (cystic lesion), and in the other, the lesion was present in the upper arm (neuroma). The patient described several months of numbness involving his right fourth and fifth digits, accompanied by pain in the right elbow, shoulder, and neck. Summary the clinical history and examination suggest dysfunction in the ulnar nerve distribution. The fourth and fifth fingers are innervated by the ulnar nerve, as are most of the intrinsic hand muscles, which are described as slightly weak. There is nothing further in the history or examination to suggest a more specific localization. Indeed, the patient has some pain in the elbow, shoulder, and neck but no tenderness in the ulnar groove. Pain into the neck associated with more distal numbness and weakness usually suggests a cervical radiculopathy.

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