Books on the topic 'After Injection'

The caudal epidural steroid injection can be a routine procedure. However, the underlying anatomy of the sacral hiatus is highly variable and can be difficult to visualize under fluoroscopy. The “blind” palpation technique has repeatedly been shown to be inferior, resulting in significantly more complications, when compared to employing contrast-enhanced fluoroscopic guidance. Ultrasound image guidance can accurately localize the sacral hiatus more consistently than the palpation technique. However, ultrasound guidance does not improve the accuracy of proper needle placement, as ultrasound cannot visualize the needle or injectate after the needle has passed under the apex of the sacral hiatus. Fluoroscopic guidance is necessary to visualize the needle and to confirm that the needle tip is extradural, extravascular, and in the epidural space, and it is likely to remain the gold standard imaging modality when carrying out caudal epidural steroid injection.

This chapter discusses neurological complications of the administration of epidural and spinal anesthesia in the obstetric population. It begins with a case report on a patient with a total spinal block, which occurs when large doses of local anesthetic intended for the epidural space are inadvertently injected into the subarachnoid space. The chapter reviews key points in recognizing and treating this potentially fatal complication. It discusses other complications, including epidural hematoma, epidural abscess, spinal cord injury, and meningitis, as well as complications from intravascular injection of local anesthetic. Lastly, it discusses how to recognize and treat the most common complication of neuraxial block, post dural puncture headache.

Pseudoaneurysms after cardiac catheterizations are not uncommon. Although most commonly they occur superficial to the common femoral artery, they are reported to occur at any location intentionally or unintentionally accessed. Ultrasound-assisted thrombin injection is a mainstay of therapy in appropriate patients. Although variations exist regarding the optimal location and amount of thrombin injection, the superior outcomes, low complication rate, and low cost associated with this method render great appeal to its utilization. This chapter describes an adjunctive technique (as well as a simple modification) to prevent the entrance of thrombin to the vasculature using a balloon to isolate the pseudoaneurysm. Although typically not necessary, this technique is valuable in the treatment of high-risk pseudoaneurysms and is well described in the literature.

Chapter 7 furthers the analysis of the role of anatomical models as cultural currencies capable of transferring value. It does so by expanding the investigation of the early stages of anatomical modelling to include a new setting. In particular, it follows the journey of the Palermitan anatomist and modeller Giuseppe Salerno and his anatomical ‘skeleton’—a specimen that represented the body’s complex web of blood vessels and was presented as the result of anatomical injections. Although Salerno was headed towards Bologna, a major centre of anatomical modelling, he ended his journey in Naples after the nobleman Raimondo di Sangro purchased the skeleton for his own cabinet of curiosities. This chapter considers the creation and viewing of an anatomical display in di Sangro’s Neapolitan Palace from a comparative perspective that highlights how geography and locality played an important part in shaping the culture of mid-eighteenth-century anatomical modelling.

Endophthalmitis refers to inflammation of both the anterior and posterior intraocular chambers and their structures. This vision-threatening condition occurs in three principal scenarios: penetrating ocular trauma, after intraocular surgery, and in systemically infected (often immunocompromised) patients. Endophthalmitis presents with marked intraocular inflammation, often with hypopyon. Patients report pain and significant vision loss out of proportion to typical post-operative complaints. It is distinguished from uveitis by both history and slit lamp examination. Endophthalmitis is an ophthalmic emergency. Same day ophthalmology consult/referral is mandatory. Vision is threatened over the course of hours. Treatment includes prompt intravitreal injection of antibiotics by an ophthalmologist. Systemic therapy should occur only in in endogenous infections, continuing until cultures clear.

Thoracic back pain patients present with associated radiculopathy, degenerative disc disease, spondylosis, stenosis, scoliosis, rib fractures, tumors, or after undergoing thoracic surgery. Thoracic transforaminal or selective nerve root blocks (SNRBs) may be both therapeutic and diagnostic. Therapeutic injections may include either local anesthetics for pain relief or corticosteroids for anti-inflammatory effects. The two types of pain amenable to therapeutic SNRBs include pain caused by irritation or direct pressure on a spinal nerve and pain originating from anatomic structures that are innervated by the sinuvertebral nerve. Although these blocks are traditionally performed under fluoroscopic guidance, computed tomography (CT) and CT fluoroscopy have been increasingly used to direct needle placement and have been advocated by experts due to superior visualization of the needle tip and the ability to clearly define spinal anatomy and adjacent soft-tissues.

The kinetics of radiotracers, that is the mode of uptake, retention and release from the myocardium, are relevant for designing and implementing optimized nuclear cardiac imaging protocols. This chapter addresses the kinetics of commonly used radiotracers for imaging myocardial perfusion, sympathetic neuronal function and cardiac metabolism, both with SPECT and PET cardiac imaging. The optimal timing of imaging after injection either at stress or at rest is determined by rate of uptake in the heart and adjacent organs, as well as the residence time of radiotracers within the myocytes. The efficiency of myocardial extraction over a wide range myocardial blood flows is relevant for reliable detection of obstructive coronary artery disease and absolute quantification of regional myocardial blood flow. For each cardiac imaging agent the cellular mechanism of uptake and its release or retention are discussed with an emphasis on the clinical impact of these parameters.

Post–dural puncture headache (PDPH) is a benign but debilitating condition that may occur as a consequence of any dural puncture, whether intentional (as with spinal anesthesia or lumbar puncture) or inadvertent (as with epidural anesthesia). The headache is characteristically unique, as it is postural in nature—worsened when sitting or standing, and markedly improved in the recumbent position. After the puncture, passage of cerebrospinal fluid (CSF) across the dura mater from a pressurized environment (subarachnoid space) to the epidural space, is the initial culprit behind the headache. Noninvasive conservative measures including hydration, analgesics, and caffeine intake are typically offered as initial treatments, but if those measures fail, the “gold standard” epidural blood patch is commonly offered. This procedure entails injection of autologous blood into the epidural space to both halt continued CSF “loss,” and to increase CSF pressure, both of which aid in headache resolution.

This chapter discusses the substantial proportion of prisoners globally who have a history of alcohol, tobacco, and other drug use and dependence. Incarceration usually provides a period of abstinence or reduced substance use, but this reduction is often transientand many ex-prisoners rapidly return to pre-incarceration levels of substance use. Substance use after release from prison is affected by both individual factors, such as substance use history and personal expectations, and interpersonal factors, such as social networks. Released prisoners often return to environments in which drugs are readily available and substance use is accepted or normative. Structural factors, such as poor access to substance use treatment and other health services, unstable housing and limited employment options, can create additional stressors that increase the risk of harmful substance use. Given the paucity of epidemiological evidence, the natural history of substance use after release from prison remains poorly understood. In particular, there is a dearth of evidence relating to resumption of alcohol, tobacco, and non-injecting illicit drug use following release from prison. Furthermore, although substance use in ex-prisoners is affected by structural and interpersonal factors, interventions to address problematic substance use typically focus on the individual. Additional research in this area is urgently needed to inform evidence-based policies and interventions.

This chapter provides an overview of skin conditions affecting the hand, including nail pathology, benign and malignant skin tumours, and Dupuytren’s disease (DD). Although distortion of the nail occurs most commonly after trauma, nail changes may indicate other systemic causes (e.g. psoriasis), and may occasionally be due to underlying malignancy. Hands are exposed to sunlight and other occupational hazards (chemicals, radiation), and are vulnerable to skin cancer, most commonly squamous cell carcinoma. DD is often familial, commoner in men, and can affect the feet (plantar fibromatosis) and penis (Peyronie’s disease). Discreet areas of DD are now treatable by collagenase injection. Surgery is still indicated to restore function, either by fasciectomy (excision of DD) or dermofasciectomy (fasciectomy plus full thickness skin graft) where skin is involved or there is a secondary skin defect following fasciectomy. Patients should be counselled realistically about the post-operative recovery to full function, and that DD is not curable by surgery.

The perception of pain is a biological mechanism which warns that damage has occurred and protects against further damage, allowing healing to occur. Acute pain often acts as an indicator of injury severity and progression or healing. The same may apply in some with chronic injuries, but in others pain may not correlate with tissue damage and/or may not be a sign that the tissue needs to be protected from mechanical stress. The management of most sports injuries involves early mobilization where possible, and pain management in the treatment of these injuries is important to allow rehabilitation to proceed and to ease distress. Modalities play an important role in this respect, and are discussed elsewhere (Chapter 2.4). Injection therapies are also discussed elsewhere (Chapter 2.6). Thorough counselling of the athlete is a priority to ensure that he/she understands what the pain represents, as this will be likely to affect compliance. For example, a degree of pain during eccentric exercise protocols in the rehabilitation of chronic tendinopathies would be anticipated, and would not contraindicate continuation of a set programme. In contrast, when an athlete is returning to sporting activities after injury, pain that is experienced during the activity would not be acceptable, and the athlete is also advised during this period that conclusions as to the tissue’s reaction to activity should not be drawn until the day after the training session. Athletes should also be taught appropriate self-help strategies to manage their pain and when this involves medication, how and when to take it. Principles for the use of medications in pain management are given in ...

Neurogenic thoracic outlet syndrome (NTOS) is an uncommon cause of chronic arm pain and numbness but should not be missed. It can lead to chronic pain and disability. Symptoms of NTOS are often aggravated by arm exertion and elevation and tend to occur after exercise rather than activity. A thorough diagnostic evaluation is key, which includes provocative tests, imaging, electromyography/nerve conduction study, and diagnostic injections. Electromyography/nerve conduction study (EMG/NCS) are recommended for NTOS as it is important to exclude an entrapment neuropathy or cervical radiculopathy that may be misdiagnosed as NTOS. EMG/NCS is usually normal in NTOS, however, in severe presentations, the EMG/NCS pattern is most consistent with a lower trunk plexopathy. Treatment options of NTOS are also described in this chapter.

Spondyloarthritis (SpA) can affect the axial skeleton (axSpA) but also manifest as peripheral arthritis, enthesitis, and dactylitis (peripheral SpA). Peripheral SpA can occur after bacterial infections (reactive arthritis) or be associated with psoriasis or inflammatory bowel disease. The arthritis is usually asymmetric, affects predominantly the lower extremity, and can be self-limiting but can also run a chronic course. The frequency of HLA-B27 is around 50% in purely peripheral SpA, while it is 70–90% in axSpA. For classification, the Amor, ESSG, or more recent ASAS criteria for peripheral SpA can be used. The ASAS criteria are likely to capture early peripheral SpA better than the other two. Therapy includes NSAIDs, local steroid injections, and synthetic disease-modifying antirheumatic drugs, of which sulfasalazine is best studied and the preferred drug for peripheral arthritis. A recent, placebo-controlled clinical trial with adalimumab may lead to the first approval of a biologic in peripheral SpA.

A technical project alongside the University courses can deepen the understanding and increase the motivation for the subject of choice. As a student, there is often a hurdle to start such a project because of a lack of inspiration. And even after overcoming this, the costs associated with such a project may put students off. With my project I show how a 3rd semester Mechanical Engineering student can design and manufacture a rocket engine with all testing components on a student budget. Cost structure and resource planning are explained in detail. I launched the project in December 2020 and in September 2021 it was presented at the StuFoExpo21. A general curiosity for the topic and a basic understanding of mechanical engineering was sufficient for starting the project. Importantly, I gained the most valuable knowledge during the implementation of the project, through active failure-iteration and reading specialised literature. The project is focussed on the design and manufacturing of a rocket engine and its testing components. A special feature is the cooling jacket of the combustion chamber. It has been 3D printed in the SLUB Makerspace, a facility at TU Dresden. Further work packages of the project were the programming of sensors and control systems, first open-air combustion tests of the injector head, safety checks and a Risk & Safety analysis. The first testing and other preliminary work were performed in collaboration with fellow students. During the entire design and manufacturing process I was in continuous exchange with the research group “Space Transportation” of the Institute of Aerospace Engineering at TU Dresden. Special thanks go to Dipl.-Ing. Jan Sieder-Katzmann and Dipl.-Ing. Maximilian Buchholz for their help during this process. For 2022 I plan a test campaign of the rocket engine to collect sensor data and to perform engine thrust measurements.

The term functional has almost replaced psychogenic in the neuromuscular literature for two reasons. It implies a disturbance of function, not structural damage; therefore, it defies laboratory testing such as MRIS, electromyography (EMG), and nerve conduction study (NCS). It is convenient to draw a parallel to the patients between migraine and brain tumors, as both cause headache, but brain MRI is negative in the former without minimizing the suffering of the patient. It is a “software” and not a “hardware” problem. It avoids irritating the patient by misunderstanding the word psychogenic which to many means “madness.”The cause of this functional impairment may fall into one of the following categories:• Conversion reaction: conversion of psychological stress to physical symptoms. This may include paralysis, hemisensory or distal sensory loss, or conversion spasms. It affects younger age groups.• Somatization: chronic multiple physical and cognitive symptoms due to chronic stress. It affects older age groups.• Factions disorder: induced real physical symptoms due to the need to be cared for, such as injecting oneself with insulin to produce hypoglycemia.• Hypochondriasis: overconcern about body functions such as suspicion of ALS due to the presence of rare fasciclutations that are normal during stress and after ingestion of a large amount of coffee. Medical students in particular are targets for this disorder.The following points are to be made on this topic. FNMD should be diagnosed by neuromuscular specialists who are trained to recognize actual syndrome whether typical or atypical. Presentations that fall out of the recognition pattern of a neuromuscular specialist, after the investigations are negative, they should be considered as FNMDs. Sometimes serial examinations are useful to confirm this suspicion. Psychatrists or psychologists are to be consulted to formulate a plan to discover the underlying stress and to treat any associated psychiatric disorder or psychological aberration. Most patients think that they are stressed due to the illness and they fail to connect the neuromuscular manifestations and the underlying stress. They offer shop around due to lack of satisfaction, especially those with somatization disorders. Some patients learn how to imitate certain conditions well, and they can deceive health care professionals. EMG and NCS are invaluable in revealing FNMD. A normal needle EMG of a weak muscles mostly indicates a central etiology (organic or functional). Normal sensory responses of a severely numb limb mean that a lesion is preganglionic (like roots avulsion, CISP, etc.) or the cause is central (a doral column lesion or functional). Management of FNMD is difficult, and many patients end up being chronic cases that wander into clinics and hospitals seeking solutions and exhausting the health care system with unnecessary expenses.It is time for these disorders to be studied in detail and be classified and have criteria set for their diagnosis so that they will not remain diagnosed only by exclusion. This chapter will describe some examples of these disorders. A video clip can tell the story better than many pages of writing. Improvement of digital cameras and electronic media has improved the diagnosis of these conditions, and it is advisable that patients record some of their symptoms when they happen. It is not uncommon for some Neuromuscular disorders (NMDs), such as myasthenia gravis (MG), small fiber neuropathy, and CISP, to be diagnosed as functional due to the lack of solid physical findings during the time of the examination. Therefore, a neuromuscular evaluation is important before these disorders are labeled as such. Some patients have genuine NMDs, but the majority of their symptoms are related to what Joseph Marsden called “sickness behavior.” A patient with carpal tunnel syndrome (CTS) may unconsciously develop numbness of the entire side of the body because he thinks that he may have a stroke.