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For corrosion to occur at all there must be a thermodynamic driving force for the oxidation of metal atoms buy 300 mg wellbutrin fast delivery. This driving force can be quantified thermodynamically using the Gibbs function quality 300 mg wellbutrin, or free energy equation (the Gibbs function incorporates both the entropy and enthalpy changes of the above chemical reaction purchase 300 mg wellbutrin, or the total work to reach equilibrium) cheap 300mg wellbutrin amex. This assumption is only really true in infinitely dilute solutions where released ions do not interact and molality equals activity, but it remains a good approximation for dilute solutions as well. By convention, if G 0, then the process requires energy; or if G 0, then the oxidation process releases energy and will spontaneously occur. There are two interrelated sources of energy to be considered in corrosion processes: chemical and electrical (charge separation). The chemical driving force ( G) determines whether or not corrosion will take place under the conditions of interest. When the free energy for oxidation is less than zero, oxidation is energetically favorable and will take place spontaneously. The second energy force relates to how the positive and negative charges (metal ions and electrons, respectively) are separated from one another during corrosion. This charge separation contributes to what is known as the electrical double layer and creates an electrical potential across the metal–solution interface (similar to that of a capacitor), which can be quantified by the expression: ∆ = −z (3) where G is the free energy change z is the valence of the ion F is known as the Faraday constant (i. Corrosion and Biocompatibility of Implants 65 This potential is also a measure of the reactivity of the metals, or the driving force for metal oxidation. It shows that the more negative the potential of a metal in solution, the more reactive it will tend to be (i. At equilibrium, the chemical energy balances with the electrical energy, which can be quantified using the Nernst equation, which defines the electrical potential across an idealized metal–solution interface when in a solution. From this equation, a theoretical scale of metal reactivity can be established, known as the electrochemical series, which is a ranking of the equilibrium potential from most positive (i. Be aware that this ranking is based only on thermodynamic equilibrium. That is, it is only true if we assume that there are no barriers (i. Table 1 shows some selected idealized reactions and their electrochemical potential (using a standard hydrogen electrode). Certain metals owe their corrosion resistance to the fact that their equilibrium potentials are very positive. Gold and platinum are examples of metals that have little or no driving force for oxidation in aqueous solutions, and thus they tend to corrode very little in the human body. However, most orthopedic metals have very negative potentials, indicating that from a chemical driving force perspective they are much more likely to corrode. For example, titanium has a very large negative potential, 1. If surface oxide formation (or passivation) did not intervene, pure titanium would react with its surroundings (typically oxygen, water, or other oxidizing species) and corrode vigorously. But it doesn’t, thanks to the formation of metal oxides. Kinetic Barriers to Corrosion: Oxide Film Formation The second primary factor that governs the corrosion process of metallic biomaterials is the formation of stable surface barriers or limitations to the kinetics of corrosion. These barriers prevent corrosion by physically limiting the rate at which oxidation or reduction processes can take place. The formation of a metal–oxide passive film on a metal surface is one example of a kinetic limitation to corrosion. The general reaction that governs this formation is as follows: z + z z − M HO2 MO zH ze 2 (5) In general, kinetic barriers to corrosion prevent either the migration of metallic ions from the metal to the solution, the migration of anions from solution to metal, or the migration of electrons across the metal–solution interface. Passive oxide films are the most well known forms of kinetic barriers in corrosion, but other kinetic barriers exist including manufactured polymeric coatings.

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Application of local heat or a warm shower may promote relaxation and help in passive stretching of tight muscles purchase wellbutrin 300mg with amex. A heated swimming pool may also help to decrease pain discount 300 mg wellbutrin amex. When the acute phase of the arthritis resolves wellbutrin 300mg on-line, low-impact exercises in the water (swimming and water aerobics) and stationary exer- cise bicycling can help improve exercise capability wellbutrin 300 mg without a prescription, muscle strength, and range of motion of the affected joint. Surgery can be helpful for people with severe joint damage. Treatment of skin involvement in psoriatic arthritis Psoriasis responds to topical corticosteroid medica- tions (ointments and creams), exposure to ultra- violet A light after application of photosensitizing psoralene—the so called psoralen-photo-augmented ultraviolet A (PUVA) treatment, or treatment with vitamin D analogs. It is inadvisable to prescribe cor- ticosteroids by mouth to treat psoriasis because this has untoward effects; in particular, the rapid taper- ing down of the dose can result in flare-up of skin disease. Refractory skin lesions may need metho- trexate or sulfasalazine. Cyclosporin has been used with good results, as has anti-TNF therapy, however, because of their side-effects and their high cost, these are only suitable for people with progres- sive disease unresponsive to other measures. It seems that once the enteritis trigger has been pulled, the chain of events takes its path anyway. However, vigorous antibiotic treatment of Chlamydia re-infections has significantly reduced relapses of reactive arthritis triggered by this organism. Reactive arthritis itself is not contagious; only the triggering bacteria are. If the preceding infec- tion is transmitted sexually, as is the case with uro- genital chlamydial infection, it is advisable for the patient’s sexual partners to be treated with anti- biotics at the same time. This helps to eradicate the infection, or at least prevent it being transmitted to others. Use of sulfasalazine or methotrexate in people unresponsive to NSAIDs Because of the efficacy of sulfasalazine in the treat- ment of inflammatory bowel disease and psoriasis even in the absence of any associated arthritis, this drug may be especially useful for spondyloarthro- pathies associated with those diseases. People with severe spondyloarthropathies with peripheral joint involvement who are unresponsive to NSAIDs and sulfasalazine have sometimes responded to weekly oral methotrexate (Rheu- matrex) therapy. Sometimes other immunosuppres- sants, such as azathioprine (Imuran), have been used in the treatment of chronic inflammatory arthritis resistant to conventional therapy. It is important to remember that sulfasalazine and immunosuppressants are relatively slow-acting anti- 140 thefacts AS-17(125-142) 5/29/02 5:55 PM Page 141 Spondyloarthropathies rheumatic drugs, so patients should not expect a quick response. Moreover, these drugs, unlike NSAIDs, are not pain relievers, although they can help relieve pain if they can first heal or control the underlying inflammation that contributes to it. Some patients with inflammatory bowel disease may need corticosteroid enemas or even oral corti- costeroids for control of severe flare-up con- sultations of the bowel disease, and also require regular follow-up consultations with their gastro- enterologist. Treatment of severe chronic inflamma- tory bowel disease, specifically Crohn’s disease, with infliximab (Remicade), is very effective, and may also control the associated arthritis and spondylitis quite well. It was established in 1988 to increase public awareness and knowledge of these diseases around the world and maintains a home page on the Internet: www. National and local There are many such support groups and organiz- ations in various countries. Their aims are to: thefacts 143 AS-App 1(143-150) 5/29/02 5:56 PM Page 144 Ankylosing spondylitis: the facts • contribute to the physical and mental health of patients with AS or related diseases • organize supervised exercise and recreational therapy groups throughout each country • arrange the exchange of experiences among the patients • oppose the social isolation of the patients • advise patients regarding social, medical and work- related problems associated with their disease • cooperate with doctors and allied health professionals • represent the interests of the patients in the society, including the legislature (law) and the health services • promote and encourage scientific research of the diseases • increase public awareness and disseminate knowledge of the diseases in their respective regions or countries. However, addresses (including homepage and e-mail addresses) and telephone and fax numbers do change from time to time. An up-to-date list is maintained by ASIF on their Internet home page, www. These and many of the other support groups listed below enlist enthusiastic patient co- operation, and provide useful information, booklets and pamphlets about AS and related spondylo- arthropathies for the people with AS and their families. Many of them can also provide advice about useful items such as wide-view mirrors for 144 thefacts AS-App 1(143-150) 5/29/02 5:56 PM Page 145 Appendix 1: Ankylosing spondylitis organizations cars, working environment, insurance needs, jobs, exercises, and so on.

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ERYTHEMA NODOSUM Erythema nodosum is not well understood wellbutrin 300 mg online, but it is believed to be an antigen-related reaction order 300mg wellbutrin amex. The condition can be acute and isolated buy generic wellbutrin 300 mg line, or chronic purchase wellbutrin 300mg overnight delivery. Erythema nodosum is asso- ciated with the use of certain medications (sulfa drugs and oral contraceptives), chronic conditions (sarcoidosis), streptococcal infections, and pregnancy. The patient may have experienced a period of arthralgia and malaise preceding the development of the skin lesion. The lesion is usually isolated, although multiple sites are possible. The lesion emerges as a firm, tender, reddened nodule, usually along the anterior aspect of the leg, although other sites can be involved. Over a period of up to 2 weeks, the lesion fades in color and the degree of firmness decreases. Chest x-ray may reveal findings consistent with sarcoidosis or another chronic condition (performed only after pregnancy is excluded). PSORIASIS (PLATE 22) Psoriasis is a chronic condition that affects the skin and is associated with arthritis. The patient often provides the history of recurrent and/or chronic skin changes that most frequently involve the extensor surfaces of extremities and scalp, although other regions are frequently involved. The lesions are described often described as itchy, although this is highly variable. The typical psoriasis lesion has a well-demarcated border, with a silvery colored scale overlying an area of obvi- ous erythema. If the scale is removed, the erythemic base reveals minute bleeding points. The shape of most lesions is oval, and several often coalesce to form one larger lesion. Patients frequently exhibit nail pitting and oncholysis. However, biopsy will reveal specific histopathologic features. LUPUS ERYTHEMATOSUS (PLATE 17) Lupus is described in more detail in Chapter 13, on the musculoskeletal system. However, this chronic connective tissue disorder does have specific dermatological findings. The patient will have a range of symptoms relevant to the diagnosis, depending on the affected organs. It is described as a “butterfly rash” because the distribution resembles a but- Copyright © 2006 F. Skin 29 terfly’s wings, as it overlies the forehead and cheeks. Other skin manifestations include dis- coid plaques, generalized photosensitivity, and lesions of erythema nodosum. LICHEN PLANUS Lichen planus is believed to be a cell-mediated response. The lesions emerge initially on the extremities and then become generalized over a period of days to weeks. The lesions then persist for months and may involve the skin over- lying all body parts. The lesions are red papules of 1 cm or greater in diameter. If performed, specific histopathologic features identified. SECONDARY SYPHILIS Secondary syphilis is commonly referred to as the “great imitator” because the associ- ated skin lesions can have a variety of presentations and appearances. The condition is caused by infection with Treponema pallidum. The onset of the rash associated with sec- ondary syphilis occurs weeks to months following the primary lesion.

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Neuroimaging: Diagnosis CT wellbutrin 300 mg otc, MRI CSF in inflammatory disease EMG: The EMG sensitivity depends on the motor involvement wellbutrin 300mg overnight delivery. Most commonly wellbutrin 300 mg lowest price, C6 and C7 roots are affected buy wellbutrin 300 mg overnight delivery, followed by C5 and C8. The sensory NCV can be expected to be normal as are the SNAPs of the median nerve (C6), third digit (C7), ulnar nerve/5th digit (C8) and the medial antebra- chial cutaneous nerve (T1). NCV motor: Injury to motor fibers distal to the cell body results in CMAP amplitude reduction. Differential diagnosis Acute cervical radiculopathies: Neuralgic amyotrophy Acute traumatic brachial plexopathy (with or without avulsions) Limitation of shoulder movement can have several causes and may be accom- panied by non-radicular pain (bursitis, capsulitis, tendinitis, impingement), muscle trauma from exercise, and frozen shoulder. Other conditions producing pain in the neck: myocardial infarction, shoul- der disease, bursitis, and arthritis. Brachial plexus lesions: Upper trunk plexus vs C 5/6 Lower trunk vs C8/T1 Middle trunk vs C7 Other considerations: Herpes infection Mononeuropathies MS (radiculopathies due to spinal cord involvement) Osteomyelitis, discitis Pancoast tumor “Pseudoradicular” symptoms Referred pain: Cardiac ischemia Spinal cord lesions Syrinx Thalamic ischemia Thoracic outlet syndrome Chronic cervical radiculopathies: ALS Multifocal motor neuropathy Mononeuropathies (e. In a study comparing conservative treatment vs surgery, the results after 12 months were equal. Neck manipulation and chiropractic maneuvers are controversial. Surgical: Used in cases of suspected myelopathy, progressive sensorimotor deficit, or failure of conservative measures. Complications: operative risks of root or cord injury, hoarseness from recurrent laryngeal nerve injury, esophageal perforation or vertebral artery injury, graft displacement. Extensive lami- nectomies carry the risk of reverse lordosis, or “swan neck deformity”. Hanley References & Belfus, Philadelphia, pp 523–584 Levin KH (2002) Cervical radiculopathies. In: Katirji B, Kaminski HJ, Preston DC, Ruff RL, Shapiro B (eds) Neuromuscular disorders in clinical practice. Butterworth Heinemann, Boston Oxford, pp 838–858 Matthews WB (1968) The neurological complications of ankylosing spondylitis. J Neurol Sci 6: 561–573 Mumenthaler M, Schliack H, Stöhr M (1998) Klinik der Läsionen der Spinalnervenwurzeln. In: Mumenthaler M, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 141–202 Radhakrishnan K, Litchy WJ, P‚Fallon WM, et al (1994) Epidemiology of cervical radicul- opathy. A population based study of Rochester, Minnesota, 1976 through 1990. Brain 117: 325–335 126 Thoracic radiculopathy Genetic testing NCV/EMG Laboratory Imaging Biopsy + + +++ Fig. Abdominal muscle weakness: A demonstrates ef- fect of abdominal muscle weak- ness in a patient with CSF certi- fied borreliosis. His first symp- tom was a feeling of distension of his abdomen. The MRT scan B demonstrates the highly atro- phic ventral abdominal mus- cles. C and D shows the charac- teristic Beevor’s sign in another patient with abdominal wall in- volvement of Borreliosis Fig. Herpes zoster: A classi- cal herpes with paraspinal-tho- racal vesicular lesions and radicular distribution (T8). C Sacral herpes zoster 127 There are twelve pairs of truncal nerves, which innervate all the muscles and Anatomy skin of the trunk. The dorsal rami separate immediately after the spinal nerves exit from the nerve root foramina. They pass through the paraspinal muscles, then divide into medial and lateral branches. T1 ventral ramus consists of a large branch that joins the C8 ventral ramus to form the lower trunk of the brachial plexus, and a smaller branch that becomes the first intercostal nerve. T2–T6 are intercostal nerves that pass around the chest wall in the intercostal spaces.

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