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These processes order retin a 0.025 line, like all metabolic procedures in hematopoetic cells with replacement of fat cells resulting the human body, are energy consumptive and dependent in a change of the fat/water ratio (Fig. The hematopoetic 201:519-523 cells occupy more than 50% of the marrow space (Courtesy of Rainer Bartl, MD, Großhadern Clinic) Fig. A decrease normal hematopoetic cells and, most important for MR imaging, of cellular marrow with age is also found in the spine. From Vande no fat cells had remained (Courtesy of Rainer Bartl, MD, Berg BC et al. Inversion recov- ery sequences with a short inversion time (STIR) can To prove or rule out metastasis of the bone, the preferred suppress fat signal by suppressing short T1-relaxation imaging modality must be able to image the whole skele- times. Bone scintigraphy is widely used, but is an indirect PD- and T2-weighted spin echo sequences also highlight method, showing indiscriminate changes of bone metab- the increased signal of water. MR imaging can detect tumor infiltration of the intensity of fat on T2-weighted fast spin echo images bone marrow space before metabolic or structural (FSE), FSE-sequences without fat suppression are not changes of trabecular or cortical bone are depicted on useful for bone marrow imaging. The most important factor to cut down scanner time to Normal hematopoetic bone marrow with near to equal acceptable times for whole body MR imaging protocols amounts of fat- and water-containing cells is depicted on are the use of appropriate hardware and sequences. Two sequences with subtraction of the transverse magnetization principle (manufacturer dependent) techniques use either of fat and water, such as opposed phase long TR GRE se- multiple surface coils and cover the whole body by these quences, with a very low signal intensity. Spin-dephasing, coils or use a especially adopted circularly polarized due to effects of magnetic susceptibility, add to the sub- body coil. For the spine, a phased array coil should be traction effect of the fat- and water-magnetization and re- used. A tendency not to increase the field-of-view but to sult in a signal void of normal hematopoetic marrow on opposed-phase GRE images.

The synapse consists of the presynaptic com- ponent (bouton) (AB1) with the presynaptic Function (C) membrane (BC2) cheap retin a 0.05 on line, the synaptic cleft (B3), and There are excitatory and inhibitory synapses. Most of the inhibitory syn- neurotubules but contains mitochondria apses are found at the perikaryon or at the and small, mainly clear vesicles (BC5) which axon hillock, where excitation is generated are clustered near the presynaptic mem- and can be most effectively suppressed. The synaptic cleft con- While synaptic vesicles are usually round, tains filamentous material and communi- some boutons contain oval or elongated cates with the extracellular space. They are characteristic of in- synaptic and postsynaptic membranes ex- hibitory synapses. Asymmetric synapses hibit dense zones of apposition, which re- (type I) are often excitatory, whereas sym- semble those found at various cell junctions metric synapses (type II) are mostly inhibi- (zonulae or maculae adherentes, adherent tory. Synapsescanbeclassifiedaccordingtotheir localization, their structure, and their func- tion, or according to the neurotransmitter substances they contain. Localization (A) The boutons may be apposed to dendrites (AC7) of the receptor neuron (axodendritic synapses) (A8, C), to small projections of the dendritic membrane, spines (axospinoussyn- apses) (A9), to the perikaryon (axosomatic synapses) (A10), or to the initial segment of the axon (axoaxonal synapses) (A11). Structure (B) Depending on the width of the synaptic cleft and the properties of the apposing membranes, two types of synapses, type I Kahle, Color Atlas of Human Anatomy, Vol. Types of Synapses 25 9 7 1 7 8 9 10 A Electron-microscopic view of a dendrite (left) and a nerve cell (right) with synapses (according to Bak) 11 5 1 B Synapses, Gray type I (left) and type II (right) 2 6 3 3 2 4 2 4 12 5 13 7 4 2 C Electron microscopic view of a cross section of a dendrite with surrounding synapses (diagram according to Uchizono) Kahle, Color Atlas of Human Anatomy, Vol. The synaptic con- The catecholamines norepinephrine (NE) tact between parallel axons and dendrites is and dopamine (DA) also act as transmitters, called parallel contact or bouton en passant and so does serotonin (5-HT). Many dendrites have thornlike projec- ropeptides act not only as hormones in the tions (spines) that form a spinous synapse bloodstream but also as transmitters in the (A2) with the bouton. Several axons for transmitter synthesis are produced in and dendrites can join to form glomerulus- the perikaryon, while the transmitter sub- like complexes in which the different synap- stances themselves are synthesized in the tic elements are closely intertwined.

At individuals may make rude or embar- times it may be difficult to discern the rassing remarks to others generic 0.1 retin a overnight delivery, exhibit inappro- extent to which depression is the direct priate sexual behavior in public, or make consequence of physiologic damage to the inappropriate sexual remarks. They may brain or a personal reaction to losses asso- misinterpret gestures of others, such as a ciated with the disability. As individuals hug, as an indication that the individual become increasingly aware of losses, desires a more passionate encounter. In restrictions, and alterations in lifestyle, some instances individuals with brain they may go through a grieving process damage may have heightened sexual drive that leads to depression. Because of the stress of adjusting to changes associated After brain damage some individuals with brain damage, lack of self-awareness have no memory of what they were like and insight, and inability to recognize prior to injury. Others may develop an cues from the environment, substance increasing awareness of their disability or abuse may become problematic post in- an awareness that they are unable to per- jury. Since individuals with brain damage form the tasks they performed previous- are more sensitive to the effects of alcohol ly. They may recognize the role changes or drugs, use often further impairs cogni- they are experiencing and may sense that tive, psychomotor, and psychosocial skills, their status has changed within the fam- making it more difficult for them to inte- ily, social, and work setting. This loss of grate into the community or into the status may diminish their self-image, so workplace. In addition, drugs and alcohol that they become preoccupied with feel- may interact with other prescribed med- ings of worthlessness and grief. Individ- uals with brain damage are also more Treatment and Management of prone to seizures. Alcohol and drugs can Brain Damage lower the seizure threshold, increasing the risk of seizures for these individuals. As Comprehensive, individualized interdis- individuals with brain damage achieve ciplinary treatment and rehabilitation greater levels of independence, the likeli- provided by a diverse team of profession- Conditions Affecting the Brain 47 als are necessary to achieve both short- arise, potential for recovery could be com- term goals and global outcomes. Consequently, in the initial ventions are directed at preventative, stages of treatment special attention is giv- restorative, and compensatory strategies. Physicians include spinal cord injury, musculoskele- involved in the care of individuals with tal injury, or injury to internal organs. In the case of atraumatic damage, individual’s care, treatment, and/or reha- direct treatment of any underlying condi- bilitation may include nurses, respiratory tions (such as hypertension, infection in therapists, physical therapists, dietitians or the case of meningitis, or diabetes in the nutrition specialists, speech/language pathol- case of stroke) is also important to stabi- ogists, audiologists, pharmacists, occupa- lize the condition and prevent further tional therapists, recreational therapists, damage from occurring.

Evaluate the Fist-compression views in the supine position may help endosteal surface of the bone to see whether there is scal- widen the scapholunate joint in some patients cheap 0.025 retin a visa. Ulnar loping or concavities along the endosteal surface of the carpal translation is a third type of carpal instability. Concavities representing endosteal scalloping are If the entire carpus moves too far ulnarly, as recognized characteristic of cartilage tissue. This would be typical for by more than one-half of the lunate positioned ulnar to an enchondroma, which is the most common intraosseous the radius when the wrist and hand are in neutral position, bone lesion of the hands. The matrix of the lesion should this would be an ulnar carpal translation type I. If the also be evaluated to see whether there are dots of calcium scaphoid is in the normal position relative to the radial that can be seen in cartilage, or whether there is a more styloid, but there is scapholunate dissociation and the re- diffuse type of bone formation as occurs in an osseous mainder of the carpus moves too far ulnarly, as men- type of tumor as from osteosarcoma. As elsewhere in the tioned for ulnar carpal translation type I, this is called ul- body, if a lesion is very well-defined and if there is bone nar carpal translation type II. The fourth and fifth types enlargement, these are indicative of an indolent or a less of carpal instabilities relate to the carpus displacing dor- aggressive type of lesion. If the carpus, as identi- struction supports the finding of an aggressive lesion, fied by the lunate, has lost its normal articulation with the such as malignancy or infection. To determine the extent radius in the lateral view and is displaced dorsally off the of a lesion, magnetic resonance (MR) is the preferred radius, this is called dorsal radiocarpal instability, or dor- method of imaging. It occurs most commonly follow- able to survey for osseous lesions throughout the body, as ing a severe dorsally impacted distal radius fracture. If many neoplastic conditions spread to other bones or even the carpus is displaced palmarly off the carpus, as iden- to the lung. There are other types of carpal instability patterns that Ganglion is another cause for a focal swelling in the hand, are better detected more by physical examination; these but usually that occurs without underlying bone deformi- will not be covered here. Glomus tumor is a less common, painful soft-tissue le- sion that may be detected with ultrasound or MR imag- ing.