William A. Weiss, MD, PhD

• Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

https://profiles.ucsf.edu/william.weiss

In spite of minimal tissue damage birth control for women 9mm buy cheap mircette 15 mcg on-line, complete ileus (absence of bowel motility) follows birth control xanax order mircette cheap, and she complains of severe bloating birth control success rate discount mircette 15mcg visa. Mild cholinomimetic stimulation with bethanechol or neostigmine is often effective in relieving these complications of surgery birth control jacksonville fl discount 15mcg mircette mastercard. Neostigmine and bethanechol in moderate doses have significantly different effects on which one of the following Ms Brown birth control zenchent order cheap mircette on line, a 28-year-old accountant birth control for women after menopause order mircette with mastercard, has been treated for myasthenia gravis for several years. She reports to the emergency department complaining of recent onset of weakness of her hands, diplopia, and difficulty swallowing. She may be suffering from a change in response to her myasthenia therapy, that is, a cholinergic or a myasthenic crisis. Which of the following is the best drug for distinguishing between myasthenic crisis (insufficient therapy) and cholinergic crisis (excessive therapy) A crop duster pilot has been accidentally exposed to a high concentration of a highly toxic agricultural organophosphate insecticide. If untreated, the cause of death from such exposure would probably be (A) Cardiac arrhythmia (B) Gastrointestinal bleeding (C) Heart failure (D) Hypotension (E) Respiratory failure 5. Mr Green has just been diagnosed with dysautonomia (chronic idiopathic autonomic insufficiency). Pyridostigmine and neostigmine may cause which one of the following in this patient Parasympathetic nerve stimulation and a slow infusion of bethanechol will each (A) Cause ganglion cell depolarization (B) Cause skeletal muscle end plate depolarization (C) Cause vasodilation (D) Increase bronchial smooth muscle tone (E) Increase heart rate 7. Actions and clinical uses of muscarinic cholinoceptor agonists include which one of the following Which of the following is a direct-acting cholinomimetic that is lipid-soluble and is used to facilitate smoking cessation Which of the following is the primary second-messenger process in the contraction of the ciliary muscle when focusing on near objects Because neostigmine acts on the enzyme cholinesterase, which is present at all cholinergic synapses, this drug increases acetylcholine effects at nicotinic junctions as well as muscarinic ones. Bethanechol, on the other hand, is a directacting agent that activates muscarinic receptors regardless of whether the receptors are innervated or not. The muscarinic receptors on vascular endothelial cells are not innervated and respond only to direct-acting drugs. The "-thion" organophosphates (those containing the P=S bond) are activated, not inactivated, by conversion to "-oxon" (P=O) derivatives. Pralidoxime has very high affinity for the phosphorus atom and is a chemical antagonist of organophosphates. Any of the cholinesterase inhibitors (choices B, C, or E) would effectively correct myasthenic crisis. However, because cholinergic crisis (if that is what is causing the symptoms) would be worsened by a cholinomimetic, we choose the shortest-acting cholinesterase inhibitor, edrophonium. Cholinesterase inhibition is typically associated with increased (never decreased) bowel activity. Parasympathetic nerve stimulation does not cause vasodilation (most vessels do not receive parasympathetic innervation), so choice (C) is incorrect. Ganglion cells and the end plate contain nicotinic receptors, which are not affected by bethanechol, a direct-acting muscarinic agonist. Muscarinic agonists cause accommodation and cyclospasm, the opposite of paralysis of accommodation (cycloplegia). Although not drugs of choice, in acute angle-closure glaucoma, this may result in a desirable increased outflow of aqueous and decreased intraocular pressure. As noted in question 6, these agents may cause bronchospasm but have no effect on neuromuscular transmission. Muscarinic agonists may also cause sweating, but drug-induced sweating is of no value in the treatment of fever. Varenicline is a lipid-soluble partial agonist at nicotinic receptors and is used to reduce craving for tobacco in smokers. The fact that the drug has no vascular effect suggests that it is an indirect-acting agent. Cholinomimetics cause smooth muscle contraction mainly through an action on M3 Gq-coupled receptors resulting in the release of intracellular calcium. Describe the second messengers involved and the effects of acetylcholine on the major List the major clinical uses of cholinomimetic agonists. Describe the pharmacodynamic differences between direct-acting and indirect-acting cholinomimetic agents. List the major pharmacokinetic differences between bethanechol, pyridostigmine, and List the major signs and symptoms of (1) organophosphate insecticide poisoning and (2) acute nicotine toxicity. C H Cholinoceptor Blockers & Cholinesterase Regenerators the cholinoceptor antagonists consist of 2 subclasses based on their spectrum of action (ie, block of muscarinic versus nicotinic receptors). Classification and Pharmacokinetics Muscarinic antagonists can be subdivided according to their selectivity for specific M receptors or their lack of such selectivity. Although the division of muscarinic receptors into subgroups is well documented (Chapters 6 and 7), only 2 distinctly receptor-selective M1 antagonists have reached clinical trials (pirenzepine and telenzepine, neither of which is used in the United States). However, as noted later, a few agents in use in the United States are somewhat selective for the M3 subtype. A major determinant of this property is the presence or absence of a permanently charged (quaternary) amine group in the drug molecule because charged molecules are less lipid-soluble (see Chapter 1). Because it is a tertiary amine, atropine is relatively lipid-soluble and readily crosses membrane barriers. In ophthalmology, topical activity (the ability to enter the eye after conjunctival administration) and duration of action are important in determining the usefulness of several antimuscarinic drugs (see Clinical Uses). Similar ability to cross lipid barriers is essential for the agents used in parkinsonism. Mechanism of Action Although several are inverse agonists, muscarinic blocking agents act like competitive (surmountable) pharmacologic antagonists; their blocking effects can be overcome by increased concentrations of muscarinic agonists. These include the ocular, bronchial, gastrointestinal, genitourinary, and secretory effects. Cardiovascular effects at therapeutic doses include an initial slowing of heart rate caused by central effects or blockade of inhibitory presynaptic muscarinic receptors on vagus nerve endings. These are followed by the tachycardia and decreased atrioventricular conduction time that would be predicted from blockade of postsynaptic muscarinic receptors in the sinus and atrioventricular nodes. M1-selective agents (not currently available in the United States) may be somewhat selective for the gastrointestinal tract. What fraction of atropine (an amine) is in the lipid-soluble form in urine of pH 7. Benztropine, biperiden, and trihexyphenidyl are representative of several antimuscarinic agents used in parkinsonism. Although not as effective as levodopa (see Chapter 28), these agents may be useful as adjuncts or when patients become unresponsive to levodopa. Benztropine is sometimes used parenterally to treat acute dystonias caused by firstgeneration antipsychotic medications. Eye-Antimuscarinic drugs are used to cause mydriasis, as indicated by the origin of the name belladonna ("beautiful lady") from the ancient cosmetic use of extracts of the Atropa belladonna plant to dilate the pupils. Bronchi-Parenteral atropine has long been used to reduce airway secretions during general anesthesia. Although not as efficacious as agonists, ipratropium is less likely to cause tachycardia and cardiac arrhythmias in sensitive patients. It has very few antimuscarinic effects outside the lungs because it is poorly absorbed and rapidly metabolized. Gut-Atropine, methscopolamine, and propantheline were used in the past to reduce acid secretion in acid-peptic disease, but are now obsolete for this indication because they are not as effective as H2 blockers (Chapter 16) and proton pump inhibitors (Chapter 59), and they cause far more frequent and severe adverse effects. The M1-selective inhibitor pirenzepine is available in Europe for the treatment of peptic ulcer. Muscarinic blockers can also be used to reduce cramping and hypermotility in transient diarrheas, but drugs such as diphenoxylate and loperamide (Chapters 31, 59) are more effective. Bladder-Oxybutynin, tolterodine, or similar agents may be used to reduce urgency in mild cystitis and to reduce bladder spasms after urologic surgery. Tolterodine, darifenacin, solifenacin, fesoterodine, and propiverine are slightly selective for M3 receptors and are promoted for the treatment of stress incontinence. Toxicity A traditional mnemonic for atropine toxicity is "Dry as a bone, hot as a pistol, red as a beet, mad as a hatter. Predictable toxicities-Antimuscarinic actions lead to several important and potentially dangerous effects. Blockade of thermoregulatory sweating may result in hyperthermia or atropine fever ("hot as a pistol"). This is the most dangerous effect of the antimuscarinic drugs in children and is potentially lethal in infants. Sweating, salivation, and lacrimation are all significantly reduced or stopped ("dry as a bone"). Moderate tachycardia is common, and severe tachycardia or arrhythmias are common with large overdoses. In the elderly, important toxicities include acute angle-closure glaucoma and urinary retention, especially in men with prostatic hyperplasia. Other drug groups with antimuscarinic effects, for example, tricyclic antidepressants, may cause hallucinations or delirium in the elderly, who are especially susceptible to antimuscarinic toxicity. At very high doses, cardiac intraventricular conduction may be blocked; this action is probably not mediated by muscarinic blockade and is difficult to treat. Dilation of the cutaneous vessels of the arms, head, neck, and trunk also occurs at these doses; the resulting "atropine flush" ("red as a beet") may be diagnostic of overdose with these drugs. Severe tachycardia may require cautious administration of small doses of physostigmine. Contraindications the antimuscarinic agents should be used cautiously in infants because of the danger of hyperthermia. The drugs are relatively contraindicated in persons with glaucoma, especially the closedangle form, and in men with prostatic hyperplasia. Ganglion-Blocking Drugs Blockers of ganglionic nicotinic receptors act like competitive pharmacologic antagonists, although there is evidence that some also block the pore of the nicotinic channel itself. These drugs were the first successful agents for the treatment of hypertension but are now obsolete for this indication. These chemical antagonists contain an oxime group, which has an extremely high affinity for the phosphorus atom in organophosphate insecticides. Because the affinity of the oxime group for phosphorus exceeds the affinity of the enzyme active site for phosphorus, these agents are able to bind the inhibitor and displace the enzyme if aging has not occurred. A 27-year old compulsive drug user injected a drug he thought was methamphetamine, but he has not developed any signs of methamphetamine action. He has been admitted to the emergency department and antimuscarinic drug overdose is suspected. Which of the following is the most dangerous effect of belladonna alkaloids in infants and toddlers Two new synthetic drugs (X and Y) are to be studied for their cardiovascular effects. The drugs are given to three anesthetized animals while the blood pressure is recorded. The first animal has received no pretreatment (control), the second has received an effective dose of a long-acting ganglion blocker, and the third has received an effective dose of a long-acting muscarinic antagonist. Drug X caused a 50 mm Hg rise in mean blood pressure in the control animal, no blood pressure change in the ganglionblocked animal, and a 75 mm mean blood pressure rise in the atropine-pretreated animal. Drug X is probably a drug similar to (A) Acetylcholine (B) Atropine (C) Epinephrine (D) Hexamethonium (E) Nicotine Vessels Glands Skeletal muscle were extensively used for this disease. Trimethaphan was the ganglion blocker most recently used in clinical practice, but it too has been almost abandoned. It was used intravenously to treat severe accelerated hypertension (malignant hypertension) and to produce controlled hypotension. Because ganglion blockers interrupt sympathetic control of venous tone, they cause marked venous pooling; postural hypotension is a major manifestation of this effect. Neuromuscular-Blocking Drugs Neuromuscular-blocking drugs are useful for producing marked skeletal muscle relaxation that is important in surgery and in mechanical ventilation of patients. The net changes in heart rate induced by drug Y in these experiments are shown in the following graph. Which one of the following drugs has a very high affinity for the phosphorus atom in parathion and is often used to treat life-threatening insecticide toxicity Nicotine can induce both parasympathomimetic and sympathomimetic effects by virtue of its ganglion-stimulating action. Hypertension and exercise-induced tachycardia reflect sympathetic discharge with norepinephrine release and therefore would not be blocked by atropine. Exerciseinduced sweating is another sympathomimetic response, but it is mediated by acetylcholine released from sympathetic nerve fibers at eccrine sweat glands.

Using gloves and towels birth control pills pcos buy generic mircette online, carefully disconnect the loaded syringe from the needle birth control pills 40s safe mircette 15 mcg, taking care not to displace the needle tip or desterilize the tip of the syringe birth control pills zoloft purchase mircette 15 mcg otc. Attach a fresh empty 10 ml to 20 ml syringe birth control 1950s buy cheap mircette 15 mcg on-line, lock it tightly onto the needle without displacement and aspirate birth control for women love purchase genuine mircette on line. If it remains appropriate to inject birth control 6 years 15mcg mircette otc, you may use the original solution providing that it is not too heavily contaminated and that the end of the syringe is kept sterile, such as by attaching it to a sterile needle. If in doubt, draw up a fresh solution, and be sure to lock the syringe tightly onto the needle. Very rarely, you may puncture a blood vessel, such as an artery at the wrist in a carpal tunnel injection. Fresh bright red arterial blood will pump into the syringe, which should be withdrawn, and firm pressure applied over the puncture site for several minutes. They usually develop spontaneously in adults 20 to 50 years of age, with a female-to-male preponderance of 3: 1. The dorsal wrist ganglion arises from the scapholunate joint and constitutes about 65% of ganglia of the wrist and hand. The volar wrist ganglion arises from the distal aspect of the radius and accounts for about 20 to 25% of ganglia. These cystic structures are found near or are attached to tendon sheaths and joint capsules. Almost all ganglia that recurred after one aspiration did not resolve with further aspirations. After aspiration and explanation of the benign nature of ganglia, only 25% of patients requested surgery. Despite this, a large number are referred to hand surgeons for advice and treatment. Patients seek advice mainly for cosmetic reasons or because of concern about malignancy or pain. For patients who remain concerned about malignancy, seeing the aspiration fluid can reinforce verbal reassurance and reduce the demand for surgical intervention. Aspiration of joints in the intercritical period (the interval between acute attacks) can also help make the diagnosis of gout. Intraarticular injection of steroid is an effective treatment; a single dose of triamcinolone acetonide, 40 mg, may resolve symptoms within 48 hours. Intraarticular injection requires a precise diagnosis and should not be used if there is a suspicion of joint infection. On the affected finger, they are often associated with nail ridging or deformity, which frequently resolves after successful injection treatment. In one study, 60% of mucoid cysts had not recurred 2 years after receiving multiple punctures with a 25 gauge needle and a small volume (<1 ml) injection of steroid and local anaesthetic. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Trigger points may manifest as regional persistent pain, tension headache, tinnitus, temporomandibular joint pain, and decreased range of motion in the legs and low back pain. The commonly encountered locations of trigger points and their pain reference zones are consistent. Warn the patient of the possibility of sharp pain, muscle twitching or an unpleasant sensation as the needle contacts the taut muscular band. The needle is then withdrawn to the level of the subcutaneous tissue and redirected superiorly, inferiorly, laterally and medially, repeating the needling and injection process in each direction until the local twitch response is no longer elicited or resisting muscle tautness is no longer perceived. Repeated injections are not recommended if two or three previous attempts have been unsuccessful. Patients are encouraged to remain active, putting muscles through their full range of motion in the week following trigger point injections. Over a 4-year period, 63 patients with Dupuytren nodules (75 hands) were treated with a series of injections with triamcinolone acetonide directly into the area of disease. The purpose of the study was to determine whether intralesional injections of triamcinolone acetonide could produce softening and flattening in nodules of Dupuytren disease, as seen in the intralesional injections of hypertrophic scars and keloids. Although some patients had complete resolution of the nodules, most experienced definite but incomplete resolution of the nodules, in the range of 60 to 80%. Although a few patients did not experience recurrence or reactivation of the disease in the injected nodules or the development of new nodules, 50% of patients did experience reactivation of disease in the nodules 1 to 3 years after the last injection, necessitating one or more injections. It involves temporally inserting small tubes into one or more entry points into the knee and running normal saline into the joint. The fluid may run out of a tube on the other side of the knee or a bag of saline may be run into the knee and then drained back into the same bag under gravity. A Cochrane review has concluded that joint lavage does not result in a relevant benefit for patients with knee osteoarthritis in terms of pain relief or improvement of function. A case highlighting the influence of knee joint effusion on muscle inhibition and size. Importance of synovial fluid aspiration when injecting intra-articular corticosteroids. A randomized controlled study of post-injection rest following intra-articular steroid therapy for knee synovitis. Intra-articular corticosteroid injections are effective in osteoarthritis but there are no clinical predictors of response. Guidance for Clinical Health Care Workers: Protection Against Infection with Blood-borne Viruses. The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Septic arthritis of the wrist: incidence, risk factors, and predictors of infection. Predictive value of synovial fluid analysis in estimating the efficacy of intra-articular corticosteroid injections in patients with rheumatoid arthritis. The added value of synovial fluid centrifugation for monosodium urate and calcium pyrophosphate crystal detection. Improved method of isolating bacteria from joint fluids by the use of blood culture bottles. Septic arthritis of the knee: the use and effect of antibiotics prior to diagnostic aspiration. Analysis for crystals in synovial fluid: training of the analysts results in high consistency. The limitations of Gram-stain microscopy of synovial fluid in concomitant septic and crystal arthritis. Poor adherence to guidelines on early management of acute hot swollen joint(s): an evaluation of clinical practice and implications for training. Derivation of a performance checklist for ultrasound-guided arthrocentesis using the modified Delphi method. Arthrocentesis and synovial fluid analysis in clinical practice: value of sonography in difficult cases. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee Comparison of ultrasoundguided and standard landmark techniques for knee arthrocentesis. Practice of ultrasoundguided arthrocentesis and joint injection, including training and implementation, in Europe: results of a survey of experts and scientific societies. Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation. Clinically, it is characterized by laryngeal oedema, bronchospasm and hypotension. A register established in 1992 recording fatal reactions gave an incidence of only 20 cases per year in the United Kingdom, of which 50% were iatrogenic, mainly occurring in hospital, 25% were related to food allergy, and 25% were related to venom allergy. Immunologically mediated reactions have rarely been observed with positive skin prick tests. A previous uneventful injection is not a guarantee that they will not be allergic this time, although it does provide some reassurance. In a fatal reaction following an intravenous drug injection or insect sting, the interval between exposure and collapse from cardiovascular shock is usually 5 to 15 minutes. The lack of any consistent clinical manifestation and a range of possible presentations cause diagnostic difficulties. Many patients with a genuine anaphylactic reaction are not given the correct treatment. Patients have been given injections of adrenaline inappropriately for allergic reactions just involving the skin or for vasovagal reactions or panic attacks. There is a range of signs and symptoms, none of which are entirely specific; however, certain combinations of signs make the diagnosis more likely. Skin or mucosal changes alone are not a sign of an anaphylactic reaction; skin and mucosal changes may be subtle or absent in up to 20% of reactions. Every clinician must prepare for the worst case scenario in their setting and have a well thought-out plan of action that is regularly reviewed in the light of current guidelines and individual experience. The immediate action to take in the presence of severe anaphylaxis is detailed in Box 1. It reverses peripheral vasodilation, reduces oedema, induces bronchodilation, has positive inotropic and chronotropic effects on the myocardium and suppresses further mediator release. Significant toxic reactions to a local anaesthetic are very unlikely with the dosages recommended in this text. Symptoms Lightheadedness Feeling drunk Signs Sedation Circumoral paraesthesia Twitching Convulsions in severe reactions Table 1. Patients who express apprehension before having an injection should lie down for the procedure; the clinician may be so intent on placing the needle correctly that the warning features are missed. Unlike an anaphylactic reaction, which appears abruptly following the procedure, there are usually warning features before or during the procedure. Distinguishing a simple faint from a fit is helped by the presence of precipitating factors. Incontinence is rare with syncope, and recovery of consciousness usually occurs within 1 minute. Always aspirate before injecting to check that the needle is not in a blood vessel. Anyone with a suspected anaphylactic reaction should be referred to an allergy specialist. If in doubt, a doctor or hospital occupational health department specialist should be consulted. The best way to avoid a needlestick injury is to be well organized and never rush an injection. All glucocorticosteroids are prohibited when administered by an oral, intravenous, intramuscular or rectal route. In accordance with the International Standard for Therapeutic Use Exemptions, a Declaration of Use must be completed by the athlete for glucocorticosteroids administered by an intraarticular, periarticular, peritendinous, epidural, intradermal and inhalation route. Athletes are responsible for any prohibited substance or its metabolites or markers found to be present in their samples. If you are not the team doctor and wish to use injection therapy for an athlete, it would be good practice to discuss this with the team doctor. If selected for a drug test, the athlete should declare the treatment on the doping control form. Virtually insoluble corticosteroids may be detectable months after the injection, although it is difficult to say just how many months. Therapeutic use exemption Athletes, like all others, may have illnesses or conditions that require them to take a particular medication. The therapeutic use of the substance would not produce significant enhancement of performance. There is no reasonable therapeutic alternative to the use of the otherwise prohibited substance or method. In professional football, the use of local anaesthetic pain-killing injections can counter the performance-reducing impact of injury and lower the rate of players missing matches through injury. In most cases, however, these injections are probably safe, although scientific evidence in this area is scant, particularly regarding long-term follow-up. Intraarticular injections to the knee, ankle, wrist, joints of the foot, pubic symphysis and major tendons of the lower limb are best avoided in most circumstances. To enable the benefit and risk profile of local anaesthetic injections to be better understood, it is recommended that professional football competitions make local anaesthetics legal only with compulsory notification. The use of local anaesthetic in professional football may reduce the rate of players missing matches through injury, but there are risks of worsening injuries and known specific complications when local anaesthetic is used. Players requesting injections should be made fully aware of these risks and complications. They will probably not admit this, but if they develop complications from the use of anabolic steroids, for example, they might blame your injection. Otherwise healthy people, especially those who seem excessively dedicated to developing their physique, need to be asked specifically about their use of illicit drugs. Thus, simply handing patients an explicit consent form may not be considered enough unless the issues are discussed with patients and they have an opportunity to ask further questions. The aim of obtaining consent should be to enable the patient to determine whether or not to undergo the proposed intervention. Information should be provided in a form and manner that help patients understand the condition and treatment options available.

Additional tests Manual tests such as repeated movements birth control pills buy online purchase discount mircette on line, individual passive joint play movements and neurological or vascular tests can be performed where indicated birth control for women ltd chicago buy 15mcg mircette. However birth control under skin order cheap mircette online, confidence in the diagnosis can be sometimes confused by too much examination; there are currently more than 120 physical examination tests described at the shoulder birth control pills in shampoo purchase mircette 15 mcg free shipping. Further objective diagnostic tests such as x-rays birth control pills good for acne cheap mircette 15 mcg, blood tests or scans need to be used judiciously when there is doubt about the diagnosis birth control questions purchase 15mcg mircette visa, or it is important to exclude unlikely but serious disorders from the differential diagnoses. A low threshold for investigation is appropriate for a patient who is systemically unwell. The cost of these investigations should always be considered; is additional information something that you need to know or something that would be nice to know, and, if so, is it worth the extra expense It is not uncommon for a patient with shoulder pain to have a scan showing subacromial bursal thickening with impingement and for the clinical examination to reveal a clear-cut capsular pattern of a frozen shoulder. Incidental findings often cause anxiety (for the patient and the clinician) and lead to further invasive, expensive, worrying tests. They may be seeking a cure or symptomatic relief, diagnostic clarification, reassurance, legitimization of symptoms, certification for work absence or to express distress, frustration or anger. Outright invention of pain is rare, but distress may lead to disproportionate pain behaviour in some patients, especially in association with chronic pain in the low back, neck or shoulder for which there is often scant objective evidence of a significant underlying organic disorder. The experienced clinician is familiar with this scenario, but the novice may be initially confused when dealing with patients who are distressed or dysfunctional. To provide effective treatment, the caring clinician needs to have an appropriate assessment and management strategy and to maintain a balance between total naivety and cynical disbelief. Injection therapy is relatively contraindicated in these cases but can be considered if the clinician thinks that the somatic pain element justifies it. Being too nice may make the patient overdependent; conversely, being too tough may cause distress and the perceived pain to increase. There is a delicate balance to be achieved in the approach to these challenging patients, and referral to a specialist in this field may be the best action. For ease of practical application, we have simplified each technique and present only the essential facts. In the three sections that follow, each double page covers one anatomical structure showing an injection technique for the most common lesion found there; the text is on the left-hand page, and on the right-hand page is a drawing of the anatomical site and a photograph of the injection position. We have selected the techniques we find to be the safest, least uncomfortable for the patient and easiest for the injector, but we also occasionally describe some equally effective or alternative ways. These are based on our own (hard-won) clinical experience and that of our colleagues. We have also introduced some clinical case histories into Sections 3 and 4, which are designed to test your diagnostic skills. The cause of the capsulitis could be osteoarthritis, systemic arthritis or trauma, but the ratio of limitation remains the same. Although things very rarely go wrong, you are tempting fate if you squeeze in an extra patient just before you have to leave promptly for an important engagement. Also, ask any accompanying family member or friend the same question, or you might suddenly find yourself dealing with two patients. Syringes All needles and syringes must be of the single-use, disposable type, and the packing must be checked to ensure that they are in date. Have available 1, 2, 5, 10 and 20 ml sterile syringes; occasionally, a 30 or 50 ml syringe might be necessary for a knee aspiration. All syringes have space that enables extra volume to be introduced; for example, a 2 ml syringe will almost always be capable of holding up to 3 ml total volume. Needles Use a large-bore needle, such as a 21 gauge, sterile, in-date needle for drawing up the drug(s). The size of the infiltrating needle depends on the size of the individual patient; select the finest needle of the appropriate length to reach the lesion. It is better to use a longer needle than might appear necessary than one that is too short, which could necessitate withdrawing and starting again. Corticosteroids In our practices, we normally use Kenalog 40 (triamcinolone acetonide, 40 mg/ ml) for these musculoskeletal injections. Adcortyl (triamcinolone acetonide, 10 mg/ml) is useful where the total volume to be injected is over 5 ml. This allows greater volume for the same dose and avoids the need to dilute the local anaesthetic further with normal saline, which is helpful when injecting hip or knee joints. It is manufactured by Intrapharm Laboratories (Maidenhead, United Kingdom) and has recently been approved; it is now back on the market after some years out of production. In our experience, Depo-Medrone (methylprednisolone) gives more postinjection flare than Kenalog, particularly in tendinous injections. We have also found that it is prone to precipitation in the syringe when mixed with a local anaesthetic. Depo-Medrone premixed with lidocaine is commonly used in the United Kingdom, but the dosage is more difficult to adjust for the individual lesion. In thin, dark-skinned patients, hydrocortisone (Hydrocortistab) may be used, especially when injecting superficial soft tissue lesions to avoid the potential risk of fat atrophy or depigmentation. Keep your drugs for joint and soft tissue injection stored in a separate place from any other injectables. Write the expiry date on the box with a thick marker pen to allow you to keep track of use-by dates, but always check the name, strength and individual expiry date of individual bottles or vials before use. There is great variation in the time to onset, with some experiencing almost immediate improvement and others taking several days. In spaces such as joints and bursae, dilution of the fluid enables the drugs to reach more areas, and slight distension of the structure helps prevent friction of the synovial surfaces. We suggest the use of lidocaine (lignocaine) hydrochloride throughout, but any suitable short-acting local anaesthetic can be used. Because of the risk of a severe allergic reaction, the patient should be carefully questioned about possible allergy to local anaesthetics. Lidocaine with epinephrine, which comes in ampoules or vials clearly marked in red, should not be used because of the risk of ischaemic necrosis in appendages. Because of its potential half-life of 8 hours or more, we do not recommend the routine use of Marcaine (bupivacaine) but it can be used occasionally when a longer anaesthetic effect is needed. Some practitioners like to mix short-acting and long-acting anaesthetics to gain both the immediate diagnostic effect and the longer therapeutic effect. Doctors and dentists frequently use drugs off label; for example, over 90% of paediatric drugs are not licensed for delivery to children, but are universally administered. In this text, we continue to include directions for mixing any suitable injectable corticosteroid with a short-acting local anaesthetic together in the syringe before injecting the patient for the reasons listed in Practice point 2. This is because the additional volume could increase symptoms, and paraesthesia, rather than pain, is the main complaint. These are guidelines only, and none are cast in stone; it is up to the clinician to decide on variants, depending on individual preference and patient presentation. At all times, however, the minimum effective dose should be given; this will help prevent the appearance of adverse side effects such as facial flushing, intermenstrual bleeding, hyperglycaemia, skin atrophy and depigmentation. This would be indicated in large areas such as the shoulder, knee or hip joints and for the subacromial bursa. These doses are less than half the maximum published in pharmacological texts, so are they are well within safety limits. Possibly the slight distension splints the structure, or perhaps breaks down or stretches out adhesions. In a small patient, the amounts are decreased, and in a large patient they may be increased. Greater volume can be obtained by using normal saline and, especially in the case of the knee joint, where the synovial folds encompass a large total area, greater volume is recommended. In the case of attempted overdistension, the back pressure created by too large a volume of injectate would almost certainly blow the syringe off the needle long before the capsule was compromised. This avoids painful distension of the structure and minimizes the risk of rupture. To accomplish this successfully, it is essential to have a high level of anatomical knowledge and can best be obtained by visiting an anatomy department and practising needle placement. This section gives tips for useful ways to localize and imagine size of anatomical structures, based on functional and surface anatomy. Wet hands carry more risk of infection, so hands must be well dried before injecting (see the technique recommended by the World Health Organization). We do recommend wearing gloves when aspirating, but they do not need to be sterile. Skin is very sensitive, especially on the flexor surfaces of the body, as is bone. Muscles, tendons and ligaments are less sensitive, and cartilage is virtually insensitive. Afterpain can be caused by a traumatic periostitis because of damaging bone with the needle or possibly by flare caused by the type of steroid used. The secret of giving a reasonably comfortable injection depends on using the needle as an extension of the finger. Once through the skin, slowly and gently pass the needle through the tissues, monitoring the texture of the structures. It does not increase the difficulty of cannulation nor cause serious adverse effects, but it is associated with mild discomfort during application. This technique has not been formally assessed for joint and soft tissue injections, but it is quick, simple and cheap and might be considered as a technique to improve patient comfort. No resistance to the introduction of fluid indicates that the needle tip is within a space. Chronic bursitis, especially at the shoulder, may result in loculation of the bursa. This gives the sensation of pockets of free flow and then resistance within the bursa, rather like injecting a sponge, so the needle must be slowly and gently moved around to infiltrate these pockets. Knowing the three-dimensional anatomical size of the structure is essential because this indicates the volume of fluid required and how much the needle tip has to be moved around. When injecting tendons in sheaths, after inserting the needle perpendicular to the skin, angle the needle alongside the tendon within the sheath and introduce the fluid. The fluid should flow easily; resistance indicates that the needle tip is within the tendon itself. Often, a small bulge is observed indicating that the fluid is contained within the sheath. If this occurs, apply firm pressure over the site for 5 minutes (vein) or 10 minutes (artery). Considerable back pressure can cause a syringe to blow off the needle, thus causing both the clinician and patient to be sprayed with the solution, an embarrassing situation. Always ensure that the needle is tightly attached to the syringe by slightly twisting the needle and syringe in opposite directions as you firmly push them together. Having placed the needle into the target site and drawn back on the plunger as usual, unexpected aspiration of blood, joint or bursal fluid may occur. To be ready for this, it is useful to have a large syringe and bowl to hand, especially when injecting large joints. Aspirate steadily, so as not to move the needle tip from the target area, and check any aspirated fluid; if the aspiration is unexpected and sepsis is suspected, detach the syringe containing the injectate from the needle, aspirate with a fresh syringe, deposit a sample of the fluid into a sterile container and send this for microscopy, sensitivity and culture. Hold the main body of the syringe (not the plunger) firmly with the other hand, and twist gently in one direction. Should the aspirated joint be injected after an aspiration, or should you await the result of the fluid analysis This depends on the experience of the aspirating clinician, the clinical context and the appearance of the fluid. If confident that the aspirate is normal serous fluid, and the clinical circumstances warrant it, injection of corticosteroid, with or without local anaesthetic, can continue. If fresh blood is removed, nothing should be injected until a fracture is eliminated. To obtain a more successful long-term result, it is essential to address the causes of the pain once the symptoms have been relieved by the injection. In our experience, nearly all common musculoskeletal lesions benefit from a few sessions of some sort of rehabilitative programme. Recurrence of symptoms is common in bursitis and tendinitis, so appropriate advice on prevention is a vital part of the care package. The ideal outcome is total relief of pain with normal power, a full range of motion and a return to previous function. When local anaesthetic is used, there should be a significant immediate improvement to encourage both patient and clinician that the correct diagnosis has been made and the injection accurately placed. The patient should be told that the relief of pain will be temporary, depending on the strength and type of anaesthetic used, and the pain may return when this effect wears off.

Industrial solvents rarely cause methemoglobinemia birth control xanax cheap 15 mcg mircette with mastercard, but this (and headaches birth control for migraine with aura purchase 15mcg mircette with visa, flushing birth control pills without estrogen cheap 15mcg mircette with mastercard, and hypotension) occur after excessive use of nitrites birth control pills 90 day cycle generic 15mcg mircette with amex. Two of the most characteristic signs of marijuana use are increased pulse rate and reddening of the conjunctiva birth control pills vs shots buy mircette pills in toronto. Phencyclidine is a weak base birth control for women 6 months cheap mircette 15 mcg mastercard, and its renal elimination may be accelerated by urinary acidification, not alkalinization! A large percentage of phencyclidine is secreted into the stomach, so removal of the drug may be hastened by activated charcoal or nasogastric suction. Describe the general principles of the management of overdose of commonly abused Identify the most likely causes of death from commonly abused drugs. Blood cell deficiency is a relatively common occurrence that can have profound repercussions. Pharmacologic treatment of these types of anemia usually involves replacement of the missing substance. An alternative therapy for certain types of anemia and for deficiency in other types of blood cells is administration of recombinant hematopoietic growth factors, which stimulate the production of various lineages of blood cells and regulate blood cell function. The cycle depends on the conversion of dihydrofolate to tetrahydrofolate by dihydrofolate reductase. Granulocyte colony-stimulating factor, a hematopoietic growth factor that regulates production and function of neutrophils Granulocyte-macrophage colony-stimulating factor, a hematopoietic growth factor that regulates production of granulocytes (basophils, eosinophils, and neutrophils), and other myeloid cells A condition of chronic excess total body iron caused either by an inherited abnormality of iron absorption or by frequent transfusions to treat certain types of hemolytic disorders (eg, thalassemia major) A group of anemias with various etiologies, characterized by abnormally large erythrocytes. Divided into megaloblastic and nonmegaloblastic subtypes, based on bone marrow findings. A deficiency in serum hemoglobin and erythrocytes in which the erythrocytes are abnormally small. Iron and Vitamin Deficiency Anemias Microcytic hypochromic anemia, caused by iron deficiency, is the most common type of anemia. Megaloblastic anemias are a subset of the macrocytic anemias and are caused by a deficiency of vitamin B12 or folic acid, cofactors required for the normal maturation of red blood cells. Pernicious anemia, the most common type of vitamin B12 deficiency anemia, is caused by a defect in the synthesis of intrinsic factor, a protein required for efficient absorption of dietary vitamin B12, or by surgical removal of that part of the stomach that secretes intrinsic factor. Other Blood Cell Deficiencies Deficiency in the concentration of the various lineages of blood cells can be a manifestation of a disease or an adverse effect of radiation or cancer chemotherapy. Some of these growth factors also play an important role in hematopoietic stem cell transplantation. Although most of the iron in the body is contained in hemoglobin, an important fraction is bound to transferrin, a transport protein, and ferritin, a storage protein. Deficiency of iron occurs most often in women because of menstrual blood loss and in vegetarians or malnourished persons because of inadequate dietary iron intake. Regulation of Iron Stores Although iron is an essential ion, excessive amounts are highly toxic. Since there is no mechanism for the efficient excretion of iron, regulation of body iron content occurs through modulation of intestinal absorption. Excess iron is stored in the protein-bound form in gastrointestinal epithelial cells, macrophages, and hepatocytes, and in cases of gross overload, in parenchymal cells of the skin, heart, and other organs. Role of Iron Iron is the essential metallic component of heme, the molecule responsible for the bulk of oxygen transport in the blood. The transferrin-iron complex binds to transferrin receptors (TfR) in erythroid precursors and hepatocytes and is internalized. After release of iron, the TfR-Tf complex is recycled to the plasma membrane and Tf is released. Hepatocytes use several mechanisms to take up iron and store the iron as ferritin. High hepatic iron stores increase hepcidin synthesis, and hepcidin inhibits ferroportin; low hepatocyte iron and 2+ increased erythroferrone inhibits hepcidin and enhances iron absorption via ferroportin. Elimination-Minimal amounts of iron are lost from the body with sweat and saliva and in exfoliated skin and intestinal mucosal cells. Clinical Use Prevention or treatment of iron deficiency anemia is the only indication for iron administration. Iron deficiency can be diagnosed from red blood cell changes (microcytic cell size due to diminished hemoglobin content) and from measurements of serum and bone marrow iron stores. The disease is treated by dietary ferrous iron supplementation with ferrous sulfate, ferrous gluconate, or ferrous fumarate. In special cases, treatment is by parenteral administration of a colloid containing a core of iron oxyhydroxide surrounded by a shell of carbohydrate. Parenteral iron preparations include iron dextran, sodium ferric gluconate complex, and iron sucrose. Iron should not be given in hemolytic anemia because iron stores are elevated, not depressed, in this type of anemia. Ferumoxytol is a super-paramagnetic iron oxide nanoparticle coated with carbohydrate. Signs and symptoms-Acute iron intoxication is most common in children and usually occurs as a result of accidental ingestion of iron supplementation tablets. Depending on the dose of iron, necrotizing gastroenteritis, shock, metabolic acidosis, coma, and death may result. Chronic iron overload, known as hemochromatosis, damages the organs that store excess iron (heart, liver, pancreas). Treatment of acute iron intoxication-Immediate treatment is necessary and usually consists of removal of unabsorbed tablets from the gut, correction of acid-base and electrolyte abnormalities, and parenteral administration of deferoxamine, which chelates circulating iron. Treatment of chronic iron toxicity-Treatment of the genetic form of hemochromatosis is usually by phlebotomy. Hemochromatosis that is due to frequent transfusions is treated with parenteral deferoxamine or with the newer oral iron chelator deferasirox. In addition, vitamin B12 deficiency can cause neurologic defects, which may become irreversible if not treated promptly. Pharmacokinetics Vitamin B12 is produced only by bacteria; this vitamin cannot be synthesized by multicellular organisms. It is found in many foods and absorbed from the gastrointestinal tract in the presence of intrinsic factor, a product of the parietal cells of the stomach. Vitamin B12 is stored in the liver in large amounts; a normal individual has enough to last 5 years. The 2 available forms of vitamin B12, cyanocobalamin and hydroxocobalamin, have similar pharmacokinetics, but hydroxocobalamin has a longer circulating half-life. Pharmacodynamics Vitamin B12 is essential in 2 reactions: conversion of methylmalonyl-coenzyme A (CoA) to succinyl-CoA and conversion of homocysteine to methionine. Section 1 shows the vitamin B12-dependent reaction that allows most dietary folates to enter the tetrahydrofolate cofactor pool and becomes the "folate trap" in vitamin B12 deficiency. Section 3 shows the pathway by which folate enters the tetrahydrofolate cofactor pool. However, the exogenous folic acid does not correct the neurologic defects of vitamin B12 deficiency. Clinical Use and Toxicity the 2 available forms of vitamin B12-hydroxocobalamin and cyanocobalamin-have equivalent effects. The major application is in the treatment of naturally occurring pernicious anemia and anemia caused by gastric resection. Because vitamin B12 deficiency anemia is almost always caused by inadequate absorption, therapy should be by replacement of vitamin B12, using parenteral therapy. How do these 3 routes compare with regard to onset and duration of drug action and risk of adverse effects In addition, deficiency of folic acid during pregnancy increases the risk of neural tube defects in the fetus. Only modest amounts are stored in the body; so a decrease in dietary intake is followed by anemia within a few months. For this reason, antifolate drugs are useful in the treatment of various infections and cancers. Clinical Use and Toxicity Folic acid deficiency is most often caused by dietary insufficiency or malabsorption. Anemia resulting from folic acid deficiency is readily treated by oral folic acid supplementation. Because maternal folic acid deficiency is associated with increased risk of neural tube defects in the fetus, folic acid supplementation is recommended before and during pregnancy. Folic acid supplements correct the anemia but not the neurologic deficits of vitamin B12 deficiency. Therefore, vitamin B12 deficiency must be ruled out before one selects folic acid as the sole therapeutic agent in the treatment of a patient with megaloblastic anemia. Through activation of receptors on erythroid progenitors in the bone marrow, erythropoietin stimulates the production of red cells and increases their release from the bone marrow. As an alternative to recombinant human erythropoietin (epoetin alfa), darbepoetin alfa, a glycosylated form of erythropoietin, has a much longer half-life. Methoxy polyethylene glycol-epoetin beta is a long-lasting form of erythropoietin that can be administered once or twice a month. Both growth factors are used to accelerate the recovery of neutrophils after cancer chemotherapy and to treat other forms of secondary and primary neutropenia (eg, aplastic anemia, congenital neutropenia). Romiplostim, a thrombopoietin receptor agonist with a novel peptide structure, is used subcutaneously in patients with chronic idiopathic thrombocytopenia who have failed to respond to conventional treatment. Eltrombopag is an oral agonist of the thrombopoietin receptor that is also used for patients with chronic idiopathic thrombocytopenia that is refractory to other agents. The risk of hepatotoxicity and hemorrhage has restricted eltrombopag use to registered physicians and patients. Toxicity associated with acute iron poisoning usually includes which of the following Correction of acid-base and electrolyte abnormalities and (A) Activated charcoal (B) Oral deferasirox (C) Parenteral deferoxamine (D) Parenteral dantrolene 5. Which of the following is most likely to be required by a 5-year-old boy with chronic renal insufficiency The megaloblastic anemia that results from vitamin B12 deficiency is due to inadequate supplies of which of the following After undergoing surgery for breast cancer, a 53-year-old woman is scheduled to receive 4 cycles of cancer chemotherapy. She is in her fourth month of pregnancy and has no history of anemia; her grandfather had pernicious anemia. If this woman has macrocytic anemia, an increased serum concentration of transferrin, and a normal serum concentration of vitamin B12, the most likely cause of her anemia is deficiency of which of the following The laboratory data for your pregnant patient indicate that she does not have macrocytic anemia but rather microcytic anemia. Optimal treatment of normocytic or mild microcytic anemia associated with pregnancy uses which of the following During the second cycle of chemotherapy, it would be appropriate to consider treating this patient with which of the following Twenty months after finishing her chemotherapy, the woman had a relapse of breast cancer. The decision was made to treat the patient with high-dose chemotherapy followed by autologous stem cell transplantation. Deficiencies of folic acid or vitamin B12 are the most common causes of megaloblastic anemia. If a patient with this type of anemia has a normal serum vitamin B12 concentration, folate deficiency is the most likely cause of the anemia. Iron deficiency microcytic anemia is the anemia that is most commonly associated with pregnancy. Acute iron poisoning often causes severe gastrointestinal damage resulting from direct corrosive effects, shock from fluid loss in the gastrointestinal tract, and metabolic acidosis from cellular dysfunction. Dantrolene inhibits Ca2+ release from the sarcoplasmic reticulum and is an antidote for malignant hyperthermia induced by inhaled anesthetics. Resection of the stomach does lead to loss of intrinsic factor and the patient will be deficient in vitamin B12. Prevention or treatment of iron deficiency anemia (microcytic cell size) is the only indication for iron administration. The kidney produces erythropoietin; patients with chronic renal insufficiency often require exogenous erythropoietin to avoid chronic anemia. The success of transplantation with peripheral blood stem cells depends on infusion of adequate numbers of hematopoietic stem cells. Like other proteinaceous drugs, the growth factors cannot be administered orally because they have very poor bioavailability. Injections are required for intravenous, intramuscular, and subcutaneous administration. The intravenous route offers the fastest onset of drug action and shortest duration of drug action. Because intravenous administration can produce high blood levels, this route of administration has the greatest risk of producing concentration-dependent drug toxicity. Intramuscular injection has a quicker onset of action than subcutaneous injection, and larger volumes of injected fluid can be given. Because protective barriers can be breached by the needle or tubing used for drug injection, all 3 of these routes of administration carry a greater risk of infection than does oral drug administration. Diagram the normal pathways of absorption, transport, and storage of iron in the Name the anemias for which iron supplementation is indicated and those for which it is contraindicated. Name 4 major hematopoietic growth factors that are used clinically and describe Explain the advantage of covalently attaching polyethylene glycol to filgrastim. The first group, the anticlotting drugs, includes some of the most commonly used drugs in the United States. Within the anticlotting group, the anticoagulant and thrombolytic drugs are effective in treatment of both venous and arterial thrombosis, whereas antiplatelet drugs are useful only for treatment of arterial disease. Its enzymatic action is markedly accelerated by the heparins System of serine proteases and substrates in the blood that provides rapid generation of clotting factors resulting in a fibrin clot, in response to blood vessel damage A protein complex on the surface of platelets.

If the patient reports increased tingling or burning pain during the procedure birth control 100 effective order discount mircette on-line, the needle should be moved before the steroid is injected around birth control late period mircette 15 mcg on line, not into birth control pills blood clot order 15 mcg mircette with amex, the nerve birth control 7 days off purchase mircette overnight delivery. Advice on avoidance of compression and reassurance as to the nature and normal outcome of the condition might be all that is required birth control pills 50 mg order 15mcg mircette fast delivery. Anterior and posterior draw test for anterior cruciate ligament/posterior cruciate ligament 8 Meniscal tests birth control 1964-89 buy mircette online from canada. The capsule is lined with synovium, which is convoluted and thus has a large surface area; in the larger knee, therefore, more volume will be required to bathe all the target area. Plicae, which are bands of synovium, might exist within the joint and can also become inflammed. One study found that total bed rest for 24 hours after injection in rheumatoid knees shows better results; however, the bed rest involved hospital stay, which is not cost-effective. Practice point In obese patients using a longer needle and a larger volume of 40 mg of Adcortyl, enables more of the joint surface to be bathed. Hyaluronans may be injected but are more expensive than corticosteroids and do not appear to have longer lasting benefits. The injection provides a variable length of pain relief, but if the knee is not overused this may be prolonged. Repeat injections can be given at intervals of not less than 3 months, with an annual x-ray to monitor joint degeneration. There are several ways to enter the knee joint; one study showed more successful placement using the supralateral approach than through the eyes of the knee, but did not compare the lateral with this medial approach. The advantage here is that there is plenty of space to insert the needle between the medial condyle and the patella, where even small amounts of serous fluid or blood can be aspirated with a large (19 gauge) needle. Sometimes an obvious effusion is difficult to aspirate; in this case, moving the needle point around within the joint may be more successful. The anterior approach is safer because the peroneal nerve lies immediately posterior to the joint. The popliteal artery and vein and posterior tibial nerve pass centrally in the popliteal fossa and must be avoided when injecting. Practice point If anything other than clear synovial fluid is removed, a specimen should be sent for culture and the appropriate treatment instigated. The swelling frequently returns at some point but can be reaspirated if the patient wishes. Practice point the lower end of the iliotibial tract itself can be irritated, but invariably the bursa is also at fault. If both lesions are suspected, infiltration of both at the same time can be performed by peppering a small amount into the tendinous insertion and injecting a bolus of remaining fluid into the bursa beneath. In a small study, it was found that the deep bursa consistently lay posterior to the distal third of the tendon and was slightly wider. A fat pad apron extends from the retropatellar fat pad to compartmentalize the bursa partially. There should be no resistance to fluid flow Deposit solution as a bolus Avoid overuse of the knee until pain free, when correction of footwear, running style and quadriceps and hamstring strengthening exercises may be necessary. When the cause is occupational, such as in carpet layers, a pad with a hole in it to relieve pressure on the bursa can be used. Practice point It is tempting to believe that pain found at the midpoint of the patellar tendon is caused by tendinitis, but in our experience, this is extremely rare at this site. Infrapatellar tendinitis is found consistently at the proximal teno-osseous junction on the patella or, rarely, at insertion into the tibial tubercle. For the superficial infrapatellar bursa and the prepatellar bursa, palpate for the centre of the tender area and, using the same equipment, inject just deep to the skin and superior to the bone. Consider using hydrocortisone for thin, darkskinned individuals to avoid skin depigmentation or fat atrophy. The bursa lies immediately under the tendon, just posterior to its insertion into the tibia, and is normally very tender to palpation. Mark tender area slightly proximal to insertion Insert needle into centre of this area, through tendon to touch bone Deposit solution as a bolus Aftercare Avoid overuse activities until pain free. A change in the causal activity and possible footwear correction or advice from a podiatrist may need to be considered. Practice point Remember that the bursa is extremely tender to palpation in everyone, so always compare palpation with the other knee. It can be found by flexing the knee to a right angle and turning the planted foot into lateral rotation. This brings the medial tibial plateau into prominence, and the tender area is found by pressing in and down onto the plateau. Practice point this lesion is commonly missed; apparent meniscal tears, anterior cruciate sprain or patellofemoral joint lesions might be simple coronary ligament sprains. It is always worth checking the ligament after a meniscal tear or surgery, as often both structures are damaged concurrently. The classic history is of the so-called cinema seat syndrome; sitting for a prolonged period in a cramped position causes pain when getting up. Often there are no objective tests, and the only sign is pain on palpation along the joint line when compared with the other knee. These ligaments usually respond extremely well to deep friction massage; it is not uncommon to cure the symptoms in one session. The injection therefore should be reserved for when the friction treatment is not available or the pain is too intense to allow the pressure of the finger. This is a fairly common knee lesion, but is usually nonrecurrent with appropriate avoidance of aggravating activities and possible use of orthotics. It is difficult to palpate the ligament because it is so thin and is intimately connected to the joint capsule. Gentle passive and active movement within the pain-free range is started immediately. Practice point Sprain of this ligament rarely needs to be injected because early physiotherapeutic treatment with ice, massage and mobilization is very effective. The injection approach could be used when this treatment is not available or the patient is in a great deal of pain. Occasionally, the distal or proximal end of the ligament is affected, so the solution can be deposited there. It is an absolute contraindication to inject corticosteroid into the body of the tendon because it is a large, weight-bearing and relatively avascular structure. Tenderness at the midpoint of the tendon is usually related to infrapatellar bursitis. Mark tender area at the origin of tendon on distal end of patella Aftercare Absolute rest from strong exercise is recommended, and when symptoms are relieved, a stretching and strengthening programme is initiated. Practice point In an older patient with a chronic tendinopathy, scanning is recommended before considering injection to ensure that there are no significant degenerative changes in the substance of the tendon. In the case of the committed athlete, or if scanning shows changes as above, a conservative physiotherapeutic approach should be used. This might include an eccentric exercise programme, a glyceryl trinitrate patch, taping, deep friction and/or electrotherapy together with running and orthotic advice. This is found by pushing the patella medially with the thumb and palpating up and under the medial edge with a finger to find the tender area. Some resistance will be felt Avoid overusing the knee until pain free, when a progressive strengthening and stretching programme may be started. Practice point this is an uncommon injection; in our experience, this lesion usually responds very well to two or three sessions of strong deep friction massage. The injection might be used therefore when friction is not available or the area is too tender or to reduce pain in the expansion prior to friction a week later, in a combination approach. The same dose and technique may be used to inject inflamed plicae around the patella rim. Advise the patient that heavy overuse will cause a recurrence of symptoms, and therefore long distance running should be curtailed. Weight control is also advised, and footwear should be assessed to ensure correct support; appropriate insoles often help maintain pain-free walking. Initiate passive joint mobilization and strengthening of the dorsiflexors and evertors, and assess muscle balance around the ankle because this is often a contributing factor. Practice point the ankle joint rarely causes problems except after severe trauma or fracture, and then often many years later. In our experience the injection is often successful in giving reasonably prolonged pain relief, provided excessive weight bearing is avoided. This can be repeated if necessary at intervals of at least 3 months with an annual x-ray to monitor degenerative changes. Practice point this is a difficult injection to perform because of the anatomical shape of the joint. If the needle does not enter the joint immediately, deposit a small amount of the mixed solution into the area. This will allow more comfortable further attempts to place the needle intraarticularly. Gross passive testing in all six directions followed by local joint gliding and palpation should identify the joint or joints involved. Mobilizing and strengthening exercises and retraining of causal activities follow. Practice point A successful outcome is more likely if sensible attention is paid to aftercare. For example, it is very difficult for an adult female ballet dancer to stop overpointing, so different dance methods should be discussed tactfully. Palpation of the collateral ligaments at the joint line on the sides of the other toes will help identify the affected joint. Practice point this treatment may be long-lasting in early degenerative disease of the first metatarsophalangeal joint but less so in advanced cases. The other toe joints are usually more easily injected from the medial or lateral aspect while under traction using a smaller dose and volume, such as 10 mg Kenalog plus 0. The safest approach is from the lateral side to avoid the posterior tibial artery and nerve. Practice point It is important to differentiate between tendinitis and bursitis here because both are caused by overuse. In bursitis, there is usually more pain on full passive plantarflexion when the heel is pressed up against the back of the tibia, thereby squeezing the bursa. Also, palpation of the bursa is very sensitive, and the pain is usually felt more at the end of rising on tiptoe rather than during the movement. Any resistance to the needle requires immediate withdrawal and repositioning well anterior to the tendon. It runs from the medial malleolus to the sustentaculum tali on the calcaneus and to the tubercle on the navicular. There should be resistance here Activity should be limited until the patient is symptom free. Orthotics are almost always necessary and, where appropriate, advice on weight loss muscle building and proprioception retraining may also help. Sprains here are not as common as at the lateral ligament, but because they do not seem to respond well to deep friction and mobilization, injection is worth trying. When this problem follows a severe sprain of the lateral ligament, the patient often is not aware of the medial pain until sometime later. The presumed cause in this case is bruising of the calcaneus as it impinges on the sustentaculum tali. It runs distally and medially from the anterior inferior edge of the lateral malleolus to attach to the talus and is a thin structure, approximately the width of the little finger. The bifurcate calcaneocuboid ligament runs from the calcaneus to the cuboid and is often also involved in ankle sprains.

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