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    To proceed in our cells generic 10 mg aciphex free shipping, all pathways must have a negative G0 buy cheap aciphex 10 mg on-line. How is this accomplished for anabolic path- ways such as glycogen synthesis? These metabolic pathways incorporate reac- tions that expend high-energy bonds to compensate for the energy-requiring steps quality 10mg aciphex. Because the G0 s for a sequence of reactions are additive, the overall pathway becomes energetically favorable. Fuels are oxidized principally by donating electrons to NAD and FAD, which then donate electrons to O2 in the electron transport chain. The caloric value of a fuel is related to its G0 for transfer of electrons to O , and its 2 reduction potential, E° (a measure of its willingness to donate, or accept, 341 342 SECTION FOUR / FUEL OXIDATION AND THE GENERATION OF ATP electrons). Because fatty acids are more reduced than carbohydrates, they have a higher caloric value. The high affinity of oxygen for electrons (a high positive reduction potential) drives fuel oxidation forward, with release of energy that In the thermodynamic perspective can be used for ATP synthesis in oxidative phosphorylation. However, smaller of energy expenditure, where amounts of ATP can be generated without the use of O2 in anaerobic energy intake to the body exceeds glycolysis. For example, in some reac- Energy intake (food) tions catalyzed by oxygenases, NADPH is the electron donor and O the electron 2 acceptor. Energy storage Metabolism (fat) Physical activity THE WAITING ROOM variable Otto Shape is a 26-year old medical student who has completed his first Adaptive thermogenesis year of medical school. He is 70 inches tall and began medical school weighing 154 lb, within his ideal weight range (see Chapter 1). By the time Obligatory energy he finished his last examination in his first year, he weighed 187 lb. He had calcu- expenditure lated his BMR at approximately 1,680 kcal, and his energy expenditure for physical exercise equal to 30% of his BMR. He planned on returning to his premedical school Cellular and organ weight in 6 weeks over the summer by eating 576 kcal less each day and playing 7 functions hours of tennis every day. However, he did a summer internship instead of playing The portion of food that is metabolized is tennis. When Otto started his second year of medical school, he weighed 210 lb. Teefore (excess T4) is a 26-year-old man who noted heat intolerance energy is obligatory (the amount of energy with heavy sweating, heart palpitations, and tremulousness. Over the past expended to do the work of the cells, the 4 months, he has lost weight in spite of a good appetite. Some energy is also expended for poorly and describes himself as feeling “jittery inside. His skin feels warm, and he is perspiring profusely. A fine hand amount of energy is used for physical exer- cise (work against the environment). To vol- tremor is observed as he extends his arms in front of his chest. His thyroid gland untarily store less energy as fat, we can vary appears to be diffusely enlarged and, on palpation, is approximately 3 times normal our caloric intake through dietary changes or size. Teefore’s thyroid gland is secreting our energy expenditure through changes in excessive amounts of the thyroid hormones T4 (tetraiodothyronine) and T3 (tri- our physical exercise. Cora Nari suffered a heart attack 8 Cora Nari is a 64-year-old woman who had a myocardial infarction 8 months ago and had a significant months ago. Although she managed to lose 6 lb since that time, she loss of functional heart muscle. The graded aerobic exercise program she started 5 weeks after her infarc- pectoris, which is a crushing or constricting tion is now followed irregularly, falling far short of the cardiac conditioning inten- pain located in the center of the chest, often sity prescribed by her cardiologist. She is readmitted to the hospital cardiac care radiating to the neck or arms (see Ann Jeina, unit (CCU) after experiencing a severe “viselike pressure” in the mid-chest area Chapters 6 and 7).

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    Secondary deforming forces are the iliopsoas discount aciphex 20mg free shipping, hamstrings proven 20mg aciphex, and adductor brevis buy cheap aciphex 20mg on-line, followed by the much less common but still deforming force muscles, the adductor magnus and pectineus. Secondary Pathology The primary pathology is the process that initiates the deformity; however, the hip tries to respond to these pathomechanics. The anatomical pathology that develops because of these pathomechanics is the femoral head starts to migrate posteriorly, laterally, and superiorly in the acetabulum under the in- fluence of the leg being positioned in adduction, flexion, and often internal rotation. This movement and abnormal force cause the acetabular rim to become deformed, opening up and developing a channel that is directed pos- terosuperiorally. Therefore, the eti- ology of the femoral neck shaft angle is another response to the abnormal pathomechanics and position of the femoral head in the acetabulum; how- ever, it is not a primary cause of hip subluxation (Figure 10. The etiology of this femoral neck shaft angle has been studied extensively using model- ing, specifically finite element analysis of the developing growth plate. Because of the pathology, the only way that a femoral head and neck will grow into its anatomically normal degree of varus is 526 Cerebral Palsy Management A B C Figure 10. The hip joint reaction force is a vector with both magnitude and direction. Both aspects of the hip reaction force are very sensitive to the position of the hip joint and the level of muscle contraction. This clearly demonstrates a low magnitude and a superomedial direction of the vector in the normal hip (B, Position B, Vector 1). The spastic hip in the typical spastic position has a somewhat higher magnitude but the direction has shifted to be more posterior and very lateral, clearly showing why these hips dislocate (B, Position A, Vector 2). If the hip is forced into the physiologic position, such as with the use of a strong orthotic, the magnitude becomes very high although the direction is better than with the spastic position. This high magnitude would likely cause severe damage to the hip joint, and this is the reason forceful bracing should not be used on the hips of young children. The modeling can also be used to evaluate the impact of different combinations of surgery (C). The spastic hip in the spastic position starts with a high force (C, Position A, Vector 1). By doing muscles lengthenings but leaving the hip in the same position, the force has only a slight reduction (C, Position A, Vector 3), and by adding a varus osteotomy but not changing the position, the force is again only slightly reduced but still poorly directed (C, Position A, Vector 4) If the position of the limb is changed after a muscle lengthening procedure, the force vector is reduced and normally directed (C, Position B, Vector 2). This modeling shows the importance of force reduction by muscle lengthening and the importance of correct limb positioning. The anatomical pathology in the spastic hip develops when the femoral head is forced posterolaterally and superiorly (B). This bends open the lateral rim and labrum and the acetabulum (C). Because the femoral head no longer compresses the medial wall of the acetabulum, the triradiate cartilage grows laterally, thereby widening the medial wall of the acetabulum and decreasing the depth of the acetabulum (A). As the femoral head continues to be laterally displaced, the lateral side of the femoral head is no longer weight bearing and develops severe osteo- porosis. The weakened osteoporotic femoral head may then collapse under the tension of the reflected head of the rectus tendon, caus- ing an indentation in the lateral aspect of the femoral head. A continued high degree of anteversion is another aspect of the second- ary pathology of hip subluxation. This anteversion is believed to be secondary to the anteversion of infancy, which does not resolve because the normal forces on the hip joint are not present. Documentation that this anteversion gets worse under the influence of spastic muscles is poor. Modeling studies in this area have been difficult to perform and, at this stage, are not very definitive.

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    If they use assistive devices buy aciphex 20mg amex, such as walkers or crutches best 10mg aciphex, they may still back- knee by allowing the forefoot to come off the floor effective 20 mg aciphex. If this occurs, the shoe should have a good wide stable heel; however, in spite of this, some children will persist with back-kneeing and can be controlled only with a KAFO that blocks knee hyperextension directly. Ground Reaction AFO Controlling crouched gait with increased knee flexion and ankle dorsiflex- ion in stance phase is best done using solid AFOs with wide anterior proxi- mal calf straps until children weigh 25 kg, usually at about 8 to 10 years of age. For children who are over 25 kg, the solid ankle ground reaction AFO, which is rear entry in the calf, is recommended (Figure 6. The use of this orthosis requires that the ankle can be brought to neutral dorsiflexion with the knee in full extension. If this cannot be accomplished, the orthosis can- not work and these children first need gastrocnemius and hamstring length- ening before the orthosis can be used successfully. The successful use of this orthotic requires that there be very little knee flexion contracture. Because this orthosis depends on the mechanics of an effective ground reaction force, the foot-to-knee axis has to be in a relatively normal alignment, meaning less than 20° of internal or external tibial torsion. This solid ground reaction AFO does not work with severe internal or external tibial torsion or severe foot malalignments. The ground reaction AFO only works when children are standing on their feet, and as such is useful only for ambulatory children. As these children get heavier, this orthosis becomes more effective; however, it also has to become stronger. As children approach 50 to 70 kg, the orthosis 194 Cerebral Palsy Management Figure 6. The most basic AFO has a solid ankle, an anterior ankle strap, and an anterior calf strap. This is the preferred or- has to be constructed with a composite of carbon fiber or laminated copoly- thotic for preambulatory children and most mer to withstand the applied forces. As children gain am- bulatory ability and the main goal of the or- The ground reaction AFO may be hinged to allow plantar flexion but limit thotic becomes preventing plantar flexion, a dorsiflexion (Figure 6. This orthosis is primarily used after surgical re- plantar flexion-limiting ankle hinge joint can construction of the feet and muscle lengthening as a bridge to allow develop- be added. The remainder of the orthotic is ment of increased muscle strength in the plantar flexors, with the long-term similar to the solid ankle, with perhaps a flat goal of individuals being free of an orthotic. However, some individuals con- sole or additional arch molds added. These tinue to use this articulated ground reaction orthosis long term. The ortho- tone-reducing features have not been shown sis can be used before surgery on rare occasions; however, a prerequisite for to change gait in any measurable way. The ar- ticulated ground reaction AFO is entered posteriorly into a circumferentially Figure 6. The solid ground reaction AFO is entered from the rear at the calf level. If there is any planovalgus This is an anticrouching orthosis and has very or varus hindfoot deformity, the foot will deform even more severely into specific requirements to work. The knee must planovalgus or varus under the strong force of the ground reaction moment. Older children weighing more than 25 kg who meet the other cri- must be less than 30°. This orthosis depends teria will usually be very comfortable with the articulated ground reaction on the action of the ground reaction force, AFO, and the orthotic will be very effective in controlling crouched gait. How- and as such is only effective when the child ever, it must be emphasized that this orthosis works only when all the indi- stands or walks and if the child has enough cations are appropriate. Another option for using the articulated ground re- weight, usually 30 kg or more. Often, these restraining straps are made of a fabric material and stretch over time, so they have to be reset fairly frequently.

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