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By R. Bram. Central Connecticut State University.

The side-chain cleavage enzyme converts cho- genic acute regulatory protein transports cholesterol lesterol to pregnenolone cheap cialis black 800 mg amex. One of the first clinical measures for to both testosterone and estradiol buy generic cialis black 800mg, but it binds with menopause is an increase in the serum concentration of higher affinity to testosterone discount 800mg cialis black mastercard. The bioactivity of FSH (and LH) generic 800 mg cialis black amex, indicative of the lack of ovarian func- testosterone is reduced by SHBG because testosterone tion. Menses starts at age 12, not age 50, and its onset cannot bind to its receptor when bound by SHBG. Excessive SHBG increases the circulating half-life of testosterone corpora lutea would likely indicate multiple ovulations by slowing the clearance and metabolism of testos- or a failure of luteal regression. SHBG does not alter the secretion of inhibin or fication is an indicator of estrogen secretion, which androgen-binding protein. The androgen diffuses to fect on the hypothalamus, increasing the basal body Sertoli cells, which contain aromatase, the enzyme temperature for a few days after ovulation. Women that converts androgens to estrogens under the influ- who, because of ovulatory problems, are having trou- ence of FSH. Therefore, Leydig cells, Sertoli cells, LH, ble getting pregnant are sometimes asked to record and FSH are required. Follistatin binds activin and their daily oral temperatures and look for the increase would reduce FSH secretion, an essential component in basal body temperature, indicating an increase in for estradiol production. Activin would increase the secretion of terone induces a secretory type of endometrium, FSH, which is a necessary component for estradiol, but whereas estrogens induce a proliferative type. Similarly, Ley- the luteal phase, when progesterone is increasing, dig cells would need LH to stimulate the production of graafian follicles are not present. FSH decreases when the influence of FSH, are needed to aromatize andro- progesterone is rising. Androgens and estrogens are known gens under the influence of LH, whereas granulosa to stimulate the closure of the epiphyses at puberty. Theca interna cells do Because eunuchs are castrated, they have no testicular contain cholesterol side-chain cleavage enzyme, source of androgen and estrogen, and the closure of which converts cholesterol to pregnenolone. In eunuchs, long bones con- theca cells do not express aromatase, they cannot con- tinue to grow, resulting in a tall stature. The theca interna has a have a positive effect in maintaining bone; however, rich blood supply. Choice B is incorrect, although eunuchs itary portal system leads to a lack of dopamine and may have elevated circulating LH (as a result of the GnRH reaching the pituitary. The absence of testes delays the closure of tion, the lack of GnRH will lead to reduced secretion the epiphyses, and androgen levels are low in eunuchs of LH and FSH, reduced ovarian function, and even- because of the lack of testes. PRL will have no effect on the ovary or inhibit ovarian follicle development. Disrup- Chapter 38 tion of the hypothalamic-pituitary axis will lead to re- duced follicular development, lack of ovulation, and 1. Although crease, but FSH will not increase because there is no LH may stimulate aromatase in granulosa cells, granu- GnRH reaching the pituitary from the disrupted axis. Estradiol synthe- Excessive ovarian androgen usually occurs in the pres- sis in the graafian follicle is unrelated to progesterone ence of excessive LH secretion or an androgen tumor synthesis in the corpus luteum and does not increase in the ovary. Inhibin is produced by granulosa cells between FSH and progesterone in regulating estradiol and inhibits the secretion of FSH. Granulosa cells do not have the en- can have local ovarian effects, it has profound in- APPENDIX A Answers to Review Questions 735 hibitory effects on FSH secretion. Inhibin has two reaction and pronuclei formation occur after the sperm forms, A and B; the subunits are the same, whereas has entered the ovum. Inhibin binds activin and space after penetration; there is no evidence that this decreases FSH secretion.

Other fractures are provide the greatest likelihood of a correct diagnosis that less specific for abuse buy 800mg cialis black with visa, but when correlated with other can be sustained in a highly adversarial legal arena discount 800mg cialis black mastercard. In the 50 years since Caffey’s original description buy cheap cialis black 800mg, ra- Classic Metaphyseal Lesion diologists have become familiar with the imaging fea- tures of commonly encountered inflicted skeletal injuries The corner fracture and bucket handle lesions de- scribed in 1957 by Caffey are frequent findings in young abused infants quality cialis black 800mg. Specificity of radiologic findings (From with permission) by assailants. Repro- duced with permis- High specificitya sion from) Classic metaphyseal lesions Rib fractures, especially posterior Scapular fractures Spinous process fractures Sternal fractures Moderate specificity Multiple fractures, especially bilateral Fractures of different ages Epiphyseal separations Vertebral body fractures and subluxations Digital fractures Complex skull fractures Common but low specificity Subperiosteal new bone formation Clavicular fractures Long bone shaft fractures * This chapter originally appeared in: von Schulthess GK, Zolli- Linear skull fractures kofer Ch L (2001) Musculoskeletal Diseases - Diagnostic Imaging and Interventional Techniques. Springer-Verlag Italia, Milan a Highest specificity applies in infants 170 P. Kleinman extends in a planar fashion through the primary spon- fracture may extend partially or completely across the giosa. The fractures are most common in seous junction, and peripherally, the fracture veers the distal femur, proximal and distal tibia, and proxi- from the physis to undercut a larger peripheral seg- mal humeri and are much less common at the elbow, ment encompassing the subperiosteal bone collar. Corner fracture and bucket-handle patterns of the classic b metaphyseal lesion (CML). Fractures (arrows) extend adjacent to the chondroosseous junction and then veer toward the diaphysis to under- cut the large peripheral segment that encompasses the subperiosteal bone collar. The frac- tures may also occur with the sudden acceleration and Most cases of osteogenesis imperfecta are accompa- deceleration of the extremities as the infant is shaken nied by blue sclera, frank bony demineralization and violently while grabbed by the thorax. When present in other typical clinical and radiologic features (Type I). However, a variety of bone fractures involve the shafts or metadiaphyseal differential considerations for the classic metaphyseal regions. The presence of demineralization Rickets and other radiologic features of osteogenesis imper- fecta confirm the diagnosis. Paterson and colleagues Metaphyseal irregularity, cupping, physeal widening and have described a group of children with metaphyseal bony demineralization are the hallmarks of rickets, how- lesions as well as other osseous injuries characteristic ever, on occasion discrete osseous fragments resembling of abuse. They coined the term “temporary brittle corner fractures may be identified in the absence of more bone disease” to explain these injuries. The diagnosis may be particu- has been widely criticized, and the lack of rigorous larly difficult if the metabolic disturbance is partially scientific methodology in their publications makes it treated because demineralization may be modest and the impossible to draw any meaningful conclusions from density of the zone of provisional calcification may be their work [8, 9]. His work has physeal fractures indistinguishable from the CML, and been strongly criticized on methodologic grounds infants with rickets undergoing vigorous passive range of. Developmental Variants Birth Injury The subperiosteal bone collar, an osseous ring that sur- Caffey noted that metaphyseal injuries identical to those rounds the primary spongiosa of the metaphysis and to occurring with abuse can result from birth injury. The tractional and torsional an abrupt step-off of the metaphyseal cortex as it ap- forces can produce metaphyseal lesions, particularly in proaches the physis. The injuries can be overlooked extend beyond the metaphysis forming a discrete lin- at birth and may be identified within the first few weeks ear mineralized spur at the periphery of the physis. These fractures are uncommon in the modern ob- These findings are most common at the knees and stetrical era and can be readily excluded by a detailed birth history. Inherited Bone Dysplasias Rib Fractures Although metaphyseal irregularity and fragmentation are seen in a variety of skeletal dysplasias, the presence Rib fractures are the most common fractures noted in of an underlying disease is usually apparent on clinical infants dying with inflicted injury. Certain bone dysplasias, anywhere along the rib arc, but are most common near however, may manifest only modest osseous changes in the costovertebral articulations. These fractures, as well early infancy, and the bony metaphyseal fragments in as fractures near the costochondral junction are the most these cases may raise strong concerns of inflicted injury. Fractures Metaphyseal chondrodysplasia, Schmid type, may pre- at the costovertebral junctions will become more visible sent in an infant of normal stature with metaphyseal on follow-up studies at two weeks; fractures at the cos- fragments indistinguishable from abuse. Similar tochondral junctions tend to heal with little subpe- findings have been described in spondylometaphyseal riosteal new bone and tend to become less distinct with dysplasia, corner fracture type. Most fractures occur with thoracic compression survey will generally point to the diagnosis. Evidence supports that excessive leverage of up skeletal survey in several weeks will show no change the ribs over the transverse processes with anteroposte- in the metaphyseal fragments in contrast to features of rior compression of the chest results in fractures of the healing noted with the CML. Kleinman a Birth Injury Rib fractures with birth injury are rare, but several re- ports suggest that obstetrical rib fractures may be more common than generally believed [14-18]. Typically, the fractures occur posterolaterally in large infants delivered by vacuum extraction and/or with shoulder dystocia. The absence of radiographic signs of healing by ten days of age on high quality radiographs helps to exclude obstetrical injury.

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