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Patient population Forty-eight hips generic super p-force oral jelly 160mg online erectile dysfunction quitting smoking, of 40 young patients Age super p-force oral jelly 160mg with visa drugs for erectile dysfunction pills, 15–49 years old (mean, 29 years) Sex: 13 women, 27 men Etiological factor: Steroid administration, 23 hips Alcohol abuse, 9; traumatic, 13 No apparent factor, 3 Type C2: 48 hips (no viable area on articular surface of the femoral head of loaded portion on preoperative anteroposterior radiographs) Stage 3B, 40 hips; 4, 8 hips (all 48 showed >3mm collapse) Anterior or posterior viable area on correct lateral radiographs Anterior, 6%–42% (mean, 21); posterior, 6%–29% (mean, 19) Posterior rotational angle: 70°–160° (mean: 126°) Additional varus position 10°–25° (mean, 19°) Follow-up, 3–20 years (mean, 9. A C B D E F Posterior Rotational Osteotomy in Femoral Head Osteonecrosis 93 Table 2. Extent of viable area of femoral head on postoperative AP and 45° flexion AP radiographs Group A Group B Group C 2/3 1/3, 2/3 <1/3 Conventional AP (n = 48) 15 (31%) 27 (56%) 6 (13%) 45° Flexion AP (n = 48) 10 (21%) 33 (69%) 5 (10%) AP, anteroposterior For postoperative management, partial weight-bearing was permitted 5 to 6 weeks after operation using two crutches. Gait with one crutch was essential for 6 months to 1 year depending on the extent of lesion. Radiographic outcome was influenced by the extent of the lateral noncollapsed living area of the femoral head corresponding to the acetabular roof on postoperative conventional anteroposterior radiographs. Extent of the noncollapsed viable area of the loaded portion of the femoral head was measured by angle, and the rate of extent was divided into three groups as follows: group A, less than the medial one- third of the weight-bearing area is involved; group B, more than one-third but less than two-thirds is involved; and group C, more than two-thirds is involved (Table 2). Anteroposterior radiographs were also taken in 45° of hip flexion [(7,8)] to observe the anterior viable portion of the femoral head. The extent of the viable area of the anterior femoral head was also divided into three groups as well on conventional anteroposterior radiographs. Prevention and progression of recollapse and progres- sive joint space narrowing were observed on the follow-up radiographs, and the relationship with the extent of viable articular surface of the femoral head was also studied. Of the remodeling after surgery, respherical contour on the collapsed area that moved medially and improvement of degenerative joint narrowing were investi- gated. The necrotic focus was moved to the medial portion of the femoral head on postoperative anteroposterior radiographs in all 48 hips. A 30-year-old woman receiving high doses of corticosteroids for treatment of multiple sclerosis. A Preoperative anteroposterior radiograph of her right hip showed extensive col- lapsed lesion without viable area on loaded portion below the acetabular roof. Arrows show anterior and posterior demarcation area between necrotic and noncollapsed viable portion. C A 150° posterior rotational osteotomy with 15° varus position was per- formed. Anteroposterior (AP) radiograph taken 3 months after operation revealed adequate viable joint surface of the femoral head below the acetabular roof. D Viable area was 82% on 45° flexion AP radiograph taken at the same time. E AP radiograph taken 11 years after operation disclosed spherical contour of the medial femoral head (arrow). Flexion was 80°, abduction was 30°, and Japa- nese Orthopaedic Association (JOA) hip score was 96 points. F A 45° flexion AP radiograph taken 11 years after operation showed sphericity of the femoral head 94 T. Respherical contour on the medial collapsed area on final anteroposterior radiographs of 35 hips was studied. Of the improvement of degenerative joint on 8 hips with joint space narrowing preoperatively, observation was made for changes of acetabular subchon- dral roof on anteroposterior radiographs at 6 months, 2 years, and final follow-up. Results On postoperative anteroposterior radiographs taken in the short period after surgery (less than 1 year), the lateral noncollapsed viable area of joint surface facing the ace- tabular roof was 21% to 100% (mean, 58) in all 48 hips. On postoperative 45° flexion anteroposterior radiographs, the lateral noncollapsed viable area was 11% to 100% (mean, 54); 10 hips showed group A (Fig. Of the extent of viable area on anteroposterior radiographs, 3 hips were in group A, 2 were in group B, and 4 were in group A (Table 3). In 40 hips of stage 3B, recollapse was found in 3 hips and joint narrowing was noted on 7 hips. Recollapse occurred on 1 hip and joint narrowing was seen on 2 of 8 hips with stage 4 (Table 4). Resphericity of the medial collapsed area of the femoral head was observed in 34 of 35 hips (97%) on the final anteroposterior radiographs (Fig.

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Binge eating 160 mg super p-force oral jelly overnight delivery erectile dysfunction treatment houston tx, particularly of sweet things generic 160 mg super p-force oral jelly mastercard ginkgo biloba erectile dysfunction treatment, is one of the neurobehavioral disturbances seen in cer- tain of the frontotemporal dementias. Hyperphagia may be one fea- ture of a more general tendency to put things in the mouth (hyperorality), for example in the Klüver-Bucy syndrome. Cross References Hyperorality; Klüver-bucy syndrome Hyperphoria Hyperphoria is a variety of heterophoria in which there is a latent upward deviation of the visual axis of one eye. Using the cover-uncover test, this may be observed clinically as the downward movement of the eye as it is uncovered. Cross References Cover tests; Heterophoria; Hypophoria Hyperpilaphesie The name given to the augmentation of tactile faculties in response to other sensory deprivation, for example touch sensation in the blind. Hyperpronation - see CHOREA, CHOREOATHETOSIS; DECEREBRATE RIGIDITY Hyperreflexia Hyperreflexia is an exaggerated briskness of the tendon reflexes. This may be physiological in an anxious patient (reflexes often denoted ++), or pathological in the context of corticospinal pathway pathology (upper motor neurone syndrome, often denoted +++). It is sometimes difficult to distinguish normally brisk reflexes from pathologically brisk reflexes. Hyperreflexia (including a jaw jerk) in isolation cannot be used to diagnose an upper motor neurone syndrome, and asymme- try of reflexes is a soft sign. On the other hand, upgoing plantar - 161 - H Hyperreligiosity responses are a hard sign of upper motor neurone pathology; other accompanying signs (weakness, sustained clonus, absent abdominal reflexes) also indicate abnormality. This may be due to impaired descending inhibitory inputs to the monosy- naptic reflex arc. Rarely pathological hyperreflexia may occur in the absence of spasticity, suggesting different neuroanatomical substrates underlying these phenomena. Hyper-reflexia without spas- ticity after unilateral infarct of the medullary pyramid. Journal of the Neurological Sciences 2000; 175: 145-155 Cross References Abdominal reflexes; Clonus; Incontinence; Jaw jerk; Reflexes; Spasticity; Upper motor neurone (UMN) syndrome; Weakness Hyperreligiosity Hyperreligiosity is a neurobehavioral symptom, manifest as sudden religious conversion, or increased and unswerving orthodoxy in devo- tion to religious rituals. It may be encountered along with hyper- graphia and hyposexuality as a feature of Geschwind’s syndrome. It has also been observed in some patients with frontotemporal demen- tia; the finding is cross-cultural, having been described in Christians, Moslems, and Sikhs. In the context of refractory epilepsy, it has been associated with reduced volume of the right hippocampus, but not right amygdala. Advances in Neurology 1991; 55: 411-421 Wuerfel J, Krishnamoorthy ES, Brown RJ et al. Religiosity is associ- ated with hippocampal but not amygdala volumes in patients with refractory epilepsy. Journal of Neurology, Neurosurgery and Psychiatry 2004; 75: 640-642 Cross References Hypergraphia; Hyposexuality Hypersexuality Hypersexuality is a pathological increase in sexual drive and activity. Recognized causes include bilateral temporal lobe damage, as in the Klüver-Bucy syndrome, septal damage, hypothalamic disease (rare) with or without subjective increase in libido, and drug-treatment in Parkinson’s disease. Sexual disinhibition may be a feature of frontal lobe syndromes, particularly of the orbitofrontal cortex. Cross References Disinhibition; Frontal lobe syndromes; Klüver-bucy syndrome - 162 - Hyperthermia H Hypersomnolence Hypersomnolence is characterized by excessive daytime sleepiness, with a tendency to fall asleep at inappropriate times and places, for example during meals, telephone conversations, at the wheel of a car. Causes of hypersomnolence include: Narcolepsy or the narcoleptic syndrome: may be accompanied by other features such as sleep paralysis, hypnagogic hallucina- tions, cataplexy Midbrain lesions Idiopathic CNS hypersomnia Kleine-Levin syndrome Nocturnal hypoventilation, due to: Obstructive sleep apnea-hypopnea syndrome (OSAHS; Pickwickian syndrome) Chest wall anomalies Neuromuscular and myopathic disorders affecting the respiratory muscles, especially the diaphragm, for example: Motor neurone disease Myotonic dystrophy Metabolic myopathies, for example, acid maltase deficiency Mitochondrial disorders Drugs: benzodiazepines, ergot-derivative dopamine agonists Post-stroke sleep-related disorders. Nocturnal hypoventilation as a consequence of obstructed breathing, often manifest as snoring, causes arterial oxygen desaturation as a con- sequence of hypopnea/apnea which may lead to disturbed sleep, repeated arousals associated with tachycardia and hypertension. Clinical signs may include a bounding hyperdynamic circulation and sometimes papilledema, as well as features of any underlying neuro- muscular disease. OSAHS may present in the neurology clinics with loss of consciousness (sleep secondary to hypersomnolence), stroke, morning headaches, and cognitive impairment (slowing). Investigations may reveal a raised hematocrit and early morning hypoxia. Sleep studies confirm nocturnal hypoventilation with dips in arterial oxygen saturation. Cross References Asterixis; Cataplexy; Papilledema; Paradoxical breathing; Snoring Hyperthermia Body temperature is usually regulated within narrow limits through the coordinating actions of a centre for temperature control (“thermo- stat”), located in the hypothalamus (anterior-preoptic area), and effec- tor mechanisms (shivering, sweating, panting, vasoconstriction, vasodilation), controlled by pathways located in or running through the posterior hypothalamus and peripherally in the autonomic nervous - 163 - H Hypertonia, Hypertonus system. Other recognized causes of hyperthermia include: Infection: bacteria, viruses (pyrogens, e.

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But 160 mg super p-force oral jelly erectile dysfunction numbness, on reflection purchase 160mg super p-force oral jelly mastercard erectile dysfunction treatment in kerala, this marks on his wrist he had tried to gnaw his hand indomitable girl realized that it might still be pos- off. Training as a nurse began as lady- preventive treatment, and resettlement of the dis- pupil at the Royal Alexandra Hospital in Rhyl, abled. Now, in 1948, the vast resources of the 148 Who’s Who in Orthopedics Ministry of Health and the Ministry of Labour are cars had recently been introduced; the roads of engaged in the treatment and resettlement of Shropshire were narrow; and the Baschurch nearly one million disabled persons. Bobby met hospitals and after-care clinics have been estab- Jonathan Hustler’s new car with its rush and hoot lished throughout the country. The beginning was: “mother intended with his precious load, and off he set in the middle of to live with me. The road was narrow, the road was long; country house with an estate of no more than Jonathan’s language grew very strong. The neighbours laughed to see the sight; Bobby drainage was primitive; the garden was so run-riot looked neither to left nor to right; till the dray and the that it was a jungle and became known as the whole of its cripple crew, safely back to the home he lion’s den; there were a few cowsheds with drew. When Jonathan started out that day, he swore that broken walls and leaking roofs—this was the nothing should bar his way, though police traps in every Baschurch Convalescent Home. The sheds were more damp and Three years later, recurrence of infection in the draughty within than without, so that open-air hip joint made it necessary for Sister Hunt to treatment was quickly enforced. An editorial, signed by Brother Aaron, One day, soon after I had returned from the Royal reads: Southern Hospital and was still on a frame, I drove the black cob in the dray to Shrewsbury to do my What causes the most excitement is the picnics. I had several cripples with me, the cripples on drays with springs and the others on one of whom was disabled only in the arm and could wagonettes. When we have reached the spot planned, climb on and off the vehicle to ask the shopkeepers to the horses are taken out and fastened to the trees and come out. As luck would have it the cob was restive all the cripples who can’t get about are put on rugs. Those on crutches play as well but ment that adds to one’s dignity and the bobby’s only they are far more artful for when they are about a yard answer was that he considered it unsafe and must take off the base they suddenly drop; of course the crutches my name and address. I told him, and thinking to reach it if they don’t and they are let stand up as if they impress him added that I used to live at Boreatton Park. All sing until they have hardly Unfortunately he knew this place only as a private any breath left to sing the National Anthem. The people lunatic asylum; my brother had let the house for that in the cottages all come out and by the look on their purpose some time after my father’s death. The police- faces we could almost believe they wished to be ill just man remarked acidly that it was just the sort of place for the sake of the picnics. There were picnics to the country and picnics This association with Robert Jones was a mile- to the seaside. The famous pony, Bobby, “the stone by which the Baschurch Convalescent dearest and wickedest of ponies,” made history Home became an orthopedic hospital. McCrae for himself when he was so often left in sole Aitken was at that time house surgeon at the charge of a cargo of cripples. Sir Frederick Royal Southern Hospital, Liverpool, and he Kenyon recorded an incident in verse. Motor wrote: 149 Who’s Who in Orthopedics There arrived from time to time in the out-patient theaters, which are essential features of a modern clinic, a woman, an outside porter from the railway hospital, became available. Consultants visit from station, and a homemade handcart like a baker’s tray Liverpool, Manchester, Birmingham, Cardiff, on perambulator wheels. The resident staff includes sur- children, perhaps as many as eight, in various forms of geons from England, Scotland, Ireland, Wales, splints. A Australia, Canada, South Africa, and the United return train had to be caught so the party was soon inspected. It was one of them; but it The outside porter was employed on arrival at was perhaps the least. As early as 1907 it had Merseyside because this was so much cheaper become obvious that extensive accommodation than bringing an assistant from Baschurch. Even and excellent facilities in the central hospital the perambulator wheels were of significance. Many families only one shilling; the ticket for a handcart was had spent their lives in the wilds of Blaenau much more expensive; and it needed only the Ffestiniog, or some remote hamlet, with a geo- good-humored domination of Miss Hunt to per- graphical horizon limited to a 20-miles radius.

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Parallel with this was the development that he met his wife Jill; they were married 3 of a clean-air operating enclosure order super p-force oral jelly 160 mg without a prescription erectile dysfunction treatment miami, the total body months later and had two children generic 160mg super p-force oral jelly amex impotence australia, Tristram and exhaust system, special instruments and the tray Henrietta. Jill was a gifted and charming hostess; system, which has made the operating room she created a beautiful home and a delightful an extension of the autoclave and significantly garden at Mere in Cheshire, where she and John reduced the rate of infection. He traveled exten- surgical innovators of this generation, died on sively, lecturing, demonstrating and operating. He will be remembered by pos- invariably provided the photographs and draw- terity for his low-friction arthroplasty of the ings for his numerous publications, including Low hip, the inspiration of a surgical revolution that Friction Arthroplasty of the Hip: Theory and brought relief to countless patients crippled by Practice. He was proud of the Centre for Hip Surgery he Charnley is assured of a permanent niche in the created and the Low Friction Society formed by annals of British orthopedic surgery. Even in his last months of life, when surely he must have been aware that his In the development of low-friction arthroplasty, health was failing, he did not cease to work and Sir John was always ready to admit serendipity plan for the future and was ready to travel to and good luck as well as help from his colleagues, Japan when invited by one of his disciples. What he never dis- aspect and would easily recall patients’ details cussed is the superhuman effort and single- from years before in a chance meeting in the long mindedness needed to achieve the aim he so corridors of the hospital. He will be missed by so many, including those Starting with a single clinical observation of a he has worked with and those he has treated and squeaking femoral head replacement, he repeated whose lives he has shaped. He was a man of many experiments on lubrication of joints and dis- talents, yet single-minded in his effort. Not discouraged, he continued with the low-friction arthroplasty must be the living Moore and Thompson femoral head replacements monument to a truly great man and benefactor articulating on a Teflon shell; the shell moved of humanity. It was at this stage that the concept of “low fric- tional torque arthroplasty” was conceived and he developed a small diameter femoral head replacement, which articulated with a thick shell of Teflon; the Teflon failed. Yet the short-term clinical results had been so spectacular that he was con- vinced of the soundness of this concept. From then onwards, with the fortuitous introduction of high-density polyethylene, all his efforts were directed toward a perfect mechanical solution to a biological problem. Furlong, who specialized in tendon repair, and finally by the Austrian School of Orthopedics. On demobilization he returned to the tutorship and was appointed honorary assistant orthopedic surgeon to the General Infirmary at Leeds in 1946 and surgeon to St. James’ Hospital, Leeds, Thorp Arch Children’s Orthopedic Hospital and to Batley, Dewsbury and Selby Voluntary Hospitals. His continuing interest in tendon surgery led to the publication in 1946 of his paper on “Recon- struction of Biceps Brachii by Pectoral Muscle Transplantation”—a work acclaimed by orthope- dic surgeons in this country and in France. The same year he was invited to become a member of what was then known as the LBK Orthopedic Club—later to be renamed the Holdsworth Club after its founder Sir Frank Holdsworth. He was elected secretary and he maintained a lively inter- John Mounsten Pemberton est in the club, where his astringent pertinent con- CLARK tributions were always welcome. In 1948 he confined his hospital work to the 1906–1982 Infirmary at Leeds and Pinderfields at Wakefield, where a center for the treatment of poliomyelitis J. He was invited to take charge officer days) was born in Leicester on November of this unit. His work at School and Leeds University, where he qualified Pinderfields Hospital, together with his consul- in 1931. After house appointments at the General tancy at the Leeds Education Authority, gave him Infirmary, Leeds, he went into general practice a vast experience in the treatment of in Dewsbury in order to pay off a student debt poliomyelitis, of club foot and of cerebral palsy, incurred to allow him to finish the course. This resulted in his nomination by Sir FRCS examination and returned to Leeds Infir- Herbert Seddon to advise Israel on the develop- mary as resident orthopedic officer under the ment of a similar poliomyelitis center, and he direction of R. Broomhead in 1938, and subse- attended that country on many occasions over the quently was appointed superintendent of the Chil- next 20 years. He was much in demand as a lec- dren’s Orthopaedic Hospital at Thorp Arch. His became FRCS in 1939 and was appointed the first mastery of the English language and literature tutor in orthopedic surgery at the University of made it inevitable that he was invited to join the Leeds in the same year. He also joined the Terri- editorial board of The Journal of Bone and Joint torial Army and served throughout the 1939–1945 Surgery and he wrote many papers on the treat- war, first in France, where he had experience of ment of poliomyelitis and tendon surgery. He forward surgery and passed through Dunkirk, and edited the Science of Fractures in Sir Harry Platt’s then in Malta, Italy and Austria, being awarded Modern Orthopedic Series and in retirement the MBE for his services.

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