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The patellofemoral joint is an arthrodial joint formed by the posterior aspect of the patella and patellofemoral groove between the condyles of the femur gastritis diet 鉉鈔邇 best buy for reglan. The Q angle determines the line of pull of the patella at the patellofemoral joint high protein diet gastritis cheap reglan 10mg mastercard. A Q angle that is below normal (negative) results in a genu varum position of the knee (bow-legged), whereas a Q angle that is above normal results in a genu valgum position (knock-kneed) (4). The major movements at the tibiofemoral joint are flexion and extension in the sagittal plane. When the knee is flexed, the tibiofemoral joint is also capable of internal and external rotation in the transverse plane. Approximately 30 of internal rotation and 45 of external rotation can be achieved at the knee (4). During the final few degrees of extension, the tibia externally rotates on the femur, which brings the knee into a closed packed, or locked, position. Large and powerful thigh muscles cross the knee joint, several of which are two-joint muscles acting on the hip joint as well. The rectus femoris is a large, two-joint muscle that originates from the anterior inferior iliac spine. The vastus lateralis and vastus medialis are pennate muscles that pull on the patella at oblique angles (20). The muscles of the posterior knee joint are the hamstrings (biceps femoris, semitendinosus, and semimembranosus), sartorius, gracilis, popliteus, and gastrocnemius. The biceps femoris (lateral hamstrings) muscle contains a long head (which originates from the ischial tuberosity and is a two-joint muscle) and a short head (which originates from the mid-femur). The biceps femoris inserts into the lateral condyle of the tibia and head of the fibula. It acts to flex and externally rotate the knee and extend and externally rotate the hip. The semimembranosus and semitendinosus (medial hamstrings) are two-joint muscles that act to flex and internally rotate the knee and extend and internally rotate the hip. The tendons of the sartorius, gracilis, and semimembranosus join together to form the pes anserinus, which inserts to the anteromedial aspect of the proximal tibia just inferior to the tibial tuberosity. The gastrocnemius muscle is a two-head and two-joint muscle that acts to flex the knee and plantarflex the ankle (18). The gastrocnemius is discussed in detail in the "Ankle and Foot" section of this chapter. The popliteus is a weak flexor of the knee but, more importantly, "unlocks" the extended knee by laterally rotating the femur on the fixed tibia. As mentioned above, the knee is a frequently injured joint, with its ligaments, menisci, and patellofemoral joint vulnerable to acute and repetitive use damage. Most knee injuries require exercise training for rehabilitation, and some require surgery as well. Predisposing factors to knee injury include the following (3,7,36): Lower extremity malalignment. Because of its structure and insertion points, the anterior cruciate ligament is more frequently injured than the posterior cruciate ligament. Classically, the anterior cruciate ligament is injured when external rotation Ligamentous sprains and tears are common in the of the tibia is coupled with a valgus force on the knee, particularly in athletes. The medial meniscus is more frequently torn than the lateral meniscus, due in part to its attachment to the medial collateral ligament. The menisci are poorly innervated and relatively avascular; thus, they are not very pain sensitive and are slow to heal following injury. The "terrible triad" is a traumatic sports injury in which the anterior cruciate ligament, medial collateral ligament, and medial meniscus are damaged simultaneously (4). Patellofemoral pain syndrome is a common disorder in young athletes (particularly females) that produces anterior knee pain. Often, patellofemoral pain syndrome is caused by an off-center line of pull of the patella, which irritates the joint surfaces and retinaculum of the knee (40). An offcenter pull of the patella can result from insufficiency muscular imbalance during knee extension (24) and from excessive varus and valgus stresses from Q angles outside of the normal range of 13 足18. Proper function and mechanics of ankles and feet are essential for most sports activities and performance of activities of daily living.
Betti and Derichinsky developed their linac radiosurgery system with a special chair gastritis diet sheet order reglan 10 mg with amex, the Betti chair gastritis esophagitis diet generic reglan 10 mg fast delivery, which moved the patient in a side to side arc motion under a stationary linac beam, and which produced a set of para-coronal arcs (4). With modern, computer controlled linear accelerators, more complex motions other than these simple arcs are possible. The Montreal technique, which involves synchronized motion of the patient couch and the gantry while the radiation beam is on, is an example of this, producing a baseball seam type of beam path (33). The rationale of using arcs with circular collimators is to concentrate radiation dose upon the target, while spreading the beam entrance and exit doses over a larger volume of nontarget tissue, theoretically reducing the overall dose and toxicity to nontarget tissue. Radiosurgery based on circular collimators produces a spherical region of high dose with steep falloff, or gradient, that is adequate for spherical targets. Irregular target volumes require the use of multiple spheres, or isocenters, abutted together to conform the dose more closely to the shape of the target so as to minimize nontarget tissue dose (34). A consequence of the multiisocenter approach is that the shape of the total dose distribution is very sensitive to the abutment of the spherical dose distributions due to their steep falloff. For this reason, it is common practice to accept 30% or greater dose variation over the irregular target volumes using circular collimation. Each rectangle represents a tungsten leaf which moves left and right across the field of view shown under computer control. Nedzi (37) showed that even crude beam shaping devices offered some conformal benefit over single isocenter treatments with circular collimators. Subsequent developments by other vendors added computer-controlled motorization to the leaves so that treatments could be carried out more efficiently. These studies are usually conducted by those who have had difficulty achieving the conformality routinely published by those experienced in multiisocenter planning. These comparisons generally demonstrate that for small to medium (up to $ 20 cm3) intracranial targets multiple static beams offer conformity with ratios of normal tissue to target tissue treatments in the range of 1. Although the multiple isocenter treatment plans in these comparisons in the literature may represent a level of plan quality achievable by an average or unfamiliar user, they do not always represent the experience of expert users. Some expert users have reported on the use of multiple isocenter足 circular collimator radiosurgery systems to plan and deliver tightly conformal dose distributions to irregularly shaped targets near radiosensitive structures, while maintaining a sharp dose gradient away from the target toward radiosensitive structures (34,46足48). The following tools are available to the treatment planner to evaluate a 3D dose distribution in order to quantify the degree to which this objective is achieved: (1) 2D isodose curves and 3D isodose surfaces, (2) dose足volume histograms, and (3) physical dose足volume figures of merit. The following sections explain the use of each of these tools in radiation therapy and radiosurgery treatment planning. It is possible to display 3D semitransparent surface renderings of constant dose levels overlaid on 3D renderings of the target volume to determine if the target adequately covered, but these can be difficult to analyze quantitatively. For this reason, 2D cross-sections of the 3D dose distribution are evaluated making it easier to quantitative assess target coverage. Although this implies submillimeter precision, the 1 pixel uncertainty in isodose position can result in a large uncertainty in dose coverage for small intracranial targets. Hence, although visual inspection of isodose plots on multiple images is commonly performed, it is cumbersome and there is a large uncertainty in assessing the dose coverage that is associated representing small targets using finite size pixels. This is simply a histogram showing the number of occurrences of each dose value within a 3D volume. The ideal treatment planning situation is one in which the target volume receives a uniform dose equal to the maximum dose, and the nontarget volume receives zero dose. Note that it can difficult to evaluate competing plans using such differential histograms (50), as demonstrated in. Above $ 40 units of dose, both plans appear to be identical, but the two plans expose differing volumes of brainstem at doses less than $ 40 units. The three properties of radiosurgery dose distributions that have been correlated with clinical outcome and that lend themselves to clinical figures of merit are (1) dose conformity, (2) dose gradient, and (3) dose homogeneity (34). Transaxial, sagittal, and coronal isodose distributions for five arcs of 1008 each delivered with a 30 mm collimator. Isodose lines in each plane increase from 10 to 90% in 10% increments, as indicated. Many investigators report isodose shells that cover in the neighborhood of at least 95% of the target volume or 99% of the target volume (17,34,46,48,53足57). A sharp dose gradient (fall off in dose with respect to distance away from the target volume) is an important characteristic of radiosurgery and stereotactic radiotherapy dose distributions. Dose gradient may be characterized by the distance required for the dose to decrease from a therapeutic (prescription) dose level to one at which no ill effects are expected (half prescription dose).
Thus gastritis symptoms weight loss purchase generic reglan line, extreme competition exists for protein adsorption due to a limited space available on the surface gastritis diet 踈譛鱶褂 discount reglan 10 mg on-line. Because of their diverse properties just described, proteins do not absorb indiscriminately to every material surface; that is, complimentary properties of the surface and of the protein as well as the relative bulk concentration of each protein determine the driving forces for adsorption (25,26). Moreover, this initial interaction is extremely important since some proteins are not free to rotate once adsorbed to material surfaces due to multiple bonding mechanisms. Thus, immediately upon adsorption, proteins are somewhat fixed in a preferred orientation or bioactivity to the bulk media that contains cells (23). Some porous biomaterial surface properties that have influenced protein adsorption events include chemistry. One of the major differences between a flat two-dimensional (2D) substrate surface and that of a 3D porous material is tortuosity. Specifically, a curved porous surface allows for greater surface area, enhanced interactions between adjacent electrons of the atoms on the surface of the pores, increased localization of point charges, and the potential for greater surface energy due to a larger juxtaposition of localized surface defects. Collectively, all of these differences between a nonporous and porous biomaterial provide for a much more complex environment for interactions between proteins and pore surfaces. It is the challenge of the porous biomaterial community to understand this challenge and thus design scaffolds that control select protein interactions. Interactions of proteins (both their adsorption and orientation or conformation) on porous biomaterials mediate cell adhesion. These interactions lead to extreme consequences for the ultimate function of an implanted device (27,28). An example of the importance of protein orientation for the adhesion of cells is illustrated in. A typical cell is pictured in this figure with integrin receptors that bind to select amino acid sequences exposed once a protein adsorbs to a surface. It is the ability of the cell to recognize such exposed amino acids that will determine whether a cell adheres or not. For example, many investigators are designing porous biomaterials to be more cytocompatible. That is, many attempts have been made to immobilize select cell adhesive epitopes in proteins. But, once implanted into bone, not only do desirable osteoblasts adhere, but so do undesirable fibroblasts (cells that contribute to soft not bony tissue juxtaposition). Not only will cell adhesion be influenced by the exposure of amino acids in adsorbed proteins, but so will subsequent cell functions. Cell adhesion and its subsequent activity will be determined by the type of integrins that the cell uses to adhere to adsorbed proteins. Moreover, specific intracellular messages that control subsequent cell functions are transferred inside the cell depending on which integrin receptors are utilized by the cell to adhere to adsorbed proteins. In this manner, it is clear that cells interact with their external environment through mechanical, electrical, and chemical signals transmitted through the cell membrane. As mentioned, cell adhesion is established through cellbinding regions of extracellular matrix proteins and respective cell-membrane-intercalated receptors. Integrins are a family of transmembrane heterodimeric glycoproteins that are receptors for specific epitopes of extracellular matrix proteins and for other cell-surface molecules (30). Integrins exist as a dimer complex composed of an a-subunit (120足 180 kDa) noncovalently associated with a b-subunit (90足 110 kDa) (31). Several of these integrins have been identified that are concentrated at loci, called focal adhesion sites, of close proximity between cells and extracellular matrices on substrates (31). Focal adhesion sites are points of aggregation of, and are physically associated with, intracellular cytoskeletal molecules that control, direct, and modulate cell function in response to extracellular signals (32). However, integrin足protein interactions are not the only mechanisms by which cells adhere. Several articles suggested that In vivo (6) and In vitro (33,34) osteoblasts (bone-forming cells) attach to an implanted material through cell membrane heparin sulfate proteoglycan interactions with, for example, heparin-binding sites on fibronectin and collagen. Moreover, Nakamura and Ozawa (6) immunohistochemically detected heparin sulfate on the membranes of osteoblasts attached to bone matrix. Whatever the method of cell attachment, protein orientation will alter from surface to surface, since neither proteins nor materials are homogeneous in properties or structure on the exterior. The existence of protein regions that are largely acidic足basic or hydrophilic足hydrophobic or have select amino acids exposed to the media will greatly influence how that protein adsorbs to a surface and, thus, its orientation. Similarly, ceramics, metals, polymers, and composites thereof have vastly different chemistries and atomic bonding mechanisms.
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To adapt a complex whole-body model to a manikin-based simulator gastritis healing reglan 10 mg discount, however gastritis symptoms buy discount reglan 10 mg online, requires considerable time and expense. The published models include some intracranial dynamics (203,204), pharmacokinetics and pharma- codynamics (205) and obstetric cardiovascular physiology (206). The best simulator from a purely educational point of view is GasMan, another screen-based simulator, developed by Jim Philip (207). As the name implies, the simulation deals only with inhaled anesthetic agents, but the manual and the teaching exercises are superb. Hundreds of physiological models have been developed, some very small, some surprisingly large and complex. No one, however, is anywhere near describing human physiology in any reasonable completeness and detail. Essentially, the physiome project is the successor to the genome project, albeit many times more difficult. The following description of the project is adapted from Bassingthwaighte (208); the original was written in 2000. The physiome is the quantitative description of the functioning organism in normal and pathophysiological states. The physiome is built upon the morphome, the quantitative description of anatomical structure, chemical and biochemical composition, and material properties of an intact organism, including its genome, proteome, cell, tissue, and organ structures up to those of the whole intact being. A fundamental and major feature of the project is the databasing of experimental observations for retrieval and evaluation. Given a project that is so huge and complex, a particular working group can be expert in only a small part of the overall project. The strategies to be worked out must therefore include how to bring models composed of many submodules together, even when the expertise in each is scattered among diverse institutions, departments, talents and constituencies. Most of the submodules are complex, requiring consideration of spatial and temporal events and processes. Submodules have to be linked to one another in a way that preserves mass balance and gives an accurate representation of variables in nonlinear complex biochemical networks with many signaling and controlling pathways. Faster computation is neededwhen using models as thinking tools and for iterative data analysis. Perhaps the most serious problem is the current lack of definitive information on kinetics and dynamics of systems, due in part to the almost total lack of databased observations, but also because, although we are nearly drowning in new information being published each day, either the information required for the modeling cannot be found, has never been obtained or is totally irrelevant. Simple things like tissue composition, material properties, and mechanical behavior of cells and tissues are not generally available. Currently, there are several subprojects, the magnitude of each of which boggles the mind. As the Economist put it, Computer organs are not for the technologically fainthearted (210). The subprojects include the Cardiome Project (211), the Microcirculatory Project (212), the Pulmonary/Respiratory Project (213,214), the Kidney Project (215), and the Coagulation Project (210). This is an enormously ambitious project, many times more difficult than the genome project. First, to fill well-defined gaps in knowledge, a huge number of devices automatically churned out mountains of carefully and precisely specified data. Second, industry, sensing that there was gold in the genome, invested (and is still investing) enormous sums of money. We have several questions and comments regarding the physiome project, questions that might apply to any very large project. These questions are intended to help sort out the potential problems, difficulties and considerations while the project is still at an early stage. The questions in the physiome project are much more difficult to formulate than those of the Genome Project. Can or should the physiome project control the data, including the content and structure, back to and including the planning of the experiment that generates the data? We worry that it may become like some software (no single person knows every detail about it) what it can do and what it cannot do. There will be an enormous library of physiological normals: equations, parameters, and so on. How will one deal with the effects of aging and responses to the environment, including exercise, hypoxia, altitude, and temperature?
