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Pain with compression of the scapular body against the thoracic wall with shoulder motion may also be an indicator of snapping scapula syndrome. Kibler [36] suggested that the latter two testing positions required substantial muscular activation involving the upper and lower trapezius and the serratus anterior muscle-weakness of any of these muscles would therefore produce increased lateral deviation of the scapular body. Thus, a difference in bilateral measurements in any of the three testing positions was considered a positive test. However, it should be noted that any study that evaluates the accuracy of a physical examination test for the detection of a specific pathology or defect, the findings on examination should always be coupled with the findings obtained from the diagnostic gold standard. In the case of scapular dyskinesis, there currently does not exist a diagnostic gold standard and, thus, inhibits study interpretation. In this test, the examiner applies an anterior and superior force to the inferomedial scapular angle to assist upward rotation and posterior tilt of the scapula while the patient flexes and/or abducts the arm. A positive test occurs when the patient reports relief of impingement-like symptoms as the scapula of the affected extremity is manipulated. Acceptable inter-rater reliability has been 228 9 Scapular Dyskinesis noid labrum followed by the Jobe test to evaluate supraspinatus strength (empty- or full-can position; however, it is advisable to use the full-can position in the setting of a positive scapular assistance test to minimize symptoms of impingement which can decrease strength measurements). The test is considered positive when the above-described scapular manipulation decreases the symptoms associated with labral injury or rotator cuff impingement. A similar test has been described for the evaluation of infraspinatus strength in overhead athletes with scapular dyskinesis [42]. With the patient standing, the examiner places on hand over the superior aspect of the involved scapula with the fingers resting on the anterior clavicle. The patient is then asked to slowly abduct the humerus (scapular plane or sagittal plane). During the process of abduction, the examiner facilitates upward rotation of the scapula by pushing upward and laterally on the inferomedial angle. This maneuver encourages increased posterior scapular tilt and may relieve symptoms of rotator cuff impingement during humeral elevation. In this maneuver, the scapula is first positioned and stabilized in a fully retracted position. With the scapula in this position, the examiner performs the dynamic labral shear test to evaluate the gle- 9. The investigators aimed to decrease the amount of retraction while also emphasizing increased posterior tilt and external rotation of the scapula. If any of the above-mentioned tests were positive, each maneuver was repeated with the addition of manual scapular repositioning. The examiner then applied a moderate force to the scapula using both their hand and forearm to encourage increased posterior tilt and external rotation without achieving full retraction. With the patient standing, the examiner manipulates the involved scapula into a position of full retraction. The patient then actively abducts the arm within the scapular plane while the examiner continues to apply a stabilizing pressure to the scapula. This posterior stabilization is maintained while the examiner performs both the dynamic labral shear test and Jobe test to assess for pathology involving the labrum or the rotator cuff, respectively [109]. With the patient standing, the examiner positions their forearm obliquely across the scapular body such that the fingers rest over the anterior shoulder. This posterior stabilization is maintained while the examiner performs the rotator cuff impingement signs [110]. However, we have chosen to focus on several of the more common conditions that we believe are closely related to scapular dyskinesis. The purpose of this section is to highlight the most important concepts related to disordered scapular motion that can subsequently be applied to other, less common shoulder pathologies that are not specifically mentioned below. With specific regard to scapular dyskinesis, maneuvers such as the scapular assistance test [26] and the scapular retraction test [41] have been developed as diagnostic methods that reposition the scapula during humeral elevation (discussed above). Periscapular strengthening and proprioceptive training are typical rehabilitation options that are most often successful at providing symptomatic improvement. The precise abnormality in scapular motion that predisposes individuals to rotator cuff disease appears to vary significantly; however, these studies have generally found decreased upward rotation, decreased posterior tilt, and increased internal rotation of the scapula in patients with rotator cuff tears or impingement. Although these associations exist, it is not known whether scapular dyskinesis is the cause or the result (or both) of rotator cuff disease.

In such cases, the managing physician should assign the pT and the stage based on the other available information. Component of pT Description Resection specimen pT category optimally is based on role in pT category resection of a single specimen. If resected in several partial specimens at the same or separate operative setting, a reasonable estimate of size and extension should be made. The estimate of multiple specimens may be based on the best combination of gross and microscopic findings, and may include reconstruction of the tumor with the assistance of the radiologist and surgeon. The presence of microscopic cancer at the Impact on pT category of positive resection margin does not affect the assignment of the pT category, which is resection margins assigned based on findings in the resection specimen and at operation. In situations in which the surgeon has left behind grossly identified tumor in performing a noncurative resection, the T category should be based on all available clinical and pathological information. Pathological tumor Tumor size may vary based on whether it is size variance based measured on an unfixed or a fixed specimen. Size is often reported on the on assessment fixed specimen, and gross impression of approach tumor size may be adjusted based on microscopic examination. The pathologist should note potential alteration in tumor size caused by fixation if it might affect staging. It is not applicable for multiple foci of in situ cancer, or for a mixed invasive and in situ cancer. Direct extension Direct extension of a primary tumor into a into an organ contiguous or adjacent organ is classified as part of the tumor (T) classification and is not classified as metastasis (M). Example: Direct extension of a primary colon cancer into the liver is categorized as T4 and is not in the M category. If pThis available (resection), then any microscopic evaluation of nodes is classified as pN. For example, assessment of the axillary nodes is sufficient to assign pN for breast cancer, and it is not necessary to microscopically confirm the status of supraclavicular nodes. Many cancer sites have specific recommendations regarding the minimum number of lymph nodes to be removed during lymph node dissection to provide optimal prognostic information. However, pathological categorization (pN) still applies even in cases in which fewer than the recommended number of lymph nodes are resected. If the size of the tumor in the regional nodal metastasis is unknown, the size of the involved lymph node may be used. The size of any mass, from a single node to a conglomerate mass of matted nodes, is used to determine the N category for some disease sites, such as head and neck. Note: Please refer to disease site chapters for specific criteria on assessment of size of regional nodal metastasis. Microscopic examination of regional nodes without resection of the primary site (during the diagnostic workup) is included in the clinical classification as cN. Microscopic examination of regional nodes with surgical resection of the primary site (surgical treatment) is categorized as pN. Example: Sentinel node biopsy performed at the time of wide re-excision for melanoma (surgical treatment) is pathological (pN). Sentinel nodes are identified by lymphatic mapping, as evidenced by nodes that concentrate a colloidal material injected near the primary tumor or in the involved organ (the most commonly used agents for sentinel node biopsy are vital stains such as isosulfan blue and/or radiotracers such as 99 Tc-sulfur colloid). Nodes that do not concentrate colloidal material and are resected along with other sentinel nodes are nonsentinel nodes, and are considered part of the sentinel node procedure. Note: this distinguishes it from a complete nodal dissection, for which the pN is assigned without the (sn) or (f) suffix. These recommendations are offered as metrics for evaluation of quality review of the extent of surgical resection and resultant pathological analysis. These minimum benchmarks should not be construed as unique indicators for additional surgical resection or adjuvant therapy if the recommended nodal count has not been met. In cases in which fewer than the recommended optimal number of lymph nodes are removed, pathological node category (pN) should be assigned and complete pathological staging applied based on whatever number of nodes are reported. A suboptimal node count may lead to further dialogue between the surgeon and pathologist to support the opportunity for further evaluation.

Maddox Rod It consists of 4-5 cylinders of red glass prisms fused side by side in a supporting disc. Retinoscope It consists of plane mirror on one side and concave mirror on the other. There is a small hole in the centre of each mirror having +2 D lens to exclude accommodative error. Use It is used to determine error of refraction and opacities of the media by parallax. Trial Frame the trial frame has three compartments namely, Inner compartment-For keeping occluder, pin hole, stenopic slit, etc. There is a spherical convex lens in the centre of the disc, having a dioptric strength of +2 D. Maddox Wing It is an instrument that dissociates the retinal images of the two eyes for near fixation. Sterilization is a process which destroys all micro-organisms including bacteria and spores. Disinfection is a process which kills pathogenic micro-organisms but has no effect on bacteria and spores. Chemical agents: Alcohols, aldehydes, phenol, halogens, surface acting agents, gases, etc. Flame: It can be used to sterilize, tips of forceps, air way cannula, spatulas etc. Autoclave (Steam under pressure): It is the most widely used method of sterilization. It is based on the principle that at the boiling point of water, the vapour pressure is equal to the atmospheric pressure. Thus if the vapour pressure is increased, the penetrating power of the steam also increases. This is useful in sterilizing various instruments, rubber articles, towels, gowns, dressing pads, swabs and eye drops. Sharp edged instruments like knives and scissors can be sterilized by steam for approximately 30 minutes. Methylated spirit (70% isopropyl alcohol): Schiotz tonometer can be sterilized by it. Formaldehyde fumigation is recommended fortnightly as a routine for optimum disinfection. It is specially used to sterilize sharp instruments as their sharpness is not affected. Hydrogen peroxide (3%): It is used for sterilizing of applanation tonometer, prisms and ophthalmoscopy lenses. Indirect ophthalmoscopy lenses, gonioscopy lenses and cryoprobes can be sterilized with it. Instruments are kept in acetone for 5 minutes and thereafter are thoroughly washed with sterile water before use. The rays can penetrate both solids and liquids without raising the temperature significantly (cold sterilization). They are used for sterilizing swabs, dressing pads, tubings, plastic syringes, etc. Non-ionizing radiations: They act as a type of hot air sterilization because they are absorbed as heat. At present, drugs that manipulate neurochemistry count as cutting-edge therapeutics.

Similarly, in the case of cigarette tobacco, potassium sulphate is the preferred source of K over potassium chloride because excess chloride can reduce the burning quality of the leaf. Calcium supply and product quality A good Ca supply is essential for osmotic regulation and pectin formation. The Ca concentration of food and fodder is important for a proper balance of the major cations. Adequate supplies of Ca prevent a number of crop quality problems, such as inner decay of cabbage, brown spot and bitter pit in apples, and empty shells in groundnuts. Although Ca supply may not increase the oil content in groundnut, the total oil yield increases as a result of the favourable effect of Ca on kernel yield. Many of the benefits of liming on crop quality stem less from Ca itself but more from indirect effects caused by changes in soil pH that increase the supplies of other elements. Magnesium supply and product quality A good supply of Mg increases the concentration of carbohydrates and also chlorophyll, carotene and related quality components that are important for grazing animals. The Mg concentration is an important quality criterion because the major cations (K, Ca and Mg) should be balanced in order to ensure the best nutritional quality in cereals. For example, excess K in grass can result in Mg deficiency leading to hypomagnesaemia or grass tetany in grazing animals. Sulphur supply and product quality As S is an important constituent of some essential amino acids (cystein, cystine and methionine), S deficiency lowers protein quality. Mustard and onions rely for pungency and flavour on S-containing substances and these are also useful for increasing resistance against infections in the plant. An adequate supply of S improves: oil percentage in seeds; seed protein content; flour quality for milling and baking; marketability of copra; quality of tobacco; nutritive value of forages; grain size of pulses and oilseeds; starch content of tubers; head size in cauliflower; and sugar content and sugar recovery in sugar cane. Micronutrient supply and product quality Because micronutrients are involved in many metabolic processes, their adequate supply is a precondition for good food quality, especially with respect to the 290 Plant nutrition for food security concentrations of proteins and vitamins. A survey of micronutrients in staple foods has been provided by Graham, Welch and Bouis (2001). The total concentration of the individual micronutrients is an important index of food and feed quality. However, some compounds containing micronutrients are utilized only partly by humans and animals. Because the concentrations of micronutrients are not determined routinely, their average concentrations are often considered for nutritional purposes although these may give only an approximate idea of actual concentrations. If a person is to be supplied with vegetables rich in Fe for better blood formation, then products with higher Fe concentrations are certainly preferable. Toxic concentrations are not only detrimental as such, but also negatively affect the composition of organic food constituents. The following comments on individual micronutrients relate to food quality: B is required in good supply for fruit and vegetable quality. B deficiency causes spots and fissures that substantially reduce produce quality and market value. Cu is required in optimal amounts for high concentrations and quality of protein and also to avoid spottiness in some fruits. A shortage of Cu partly combined with Co deficiency in grass retards the growth of grazing animals, and metabolic disorders manifest in the so-called "lick disease". Fe in green-leaf vegetables such as spinach is an important source of Fe for humans. Mn raises the concentrations of some vitamins, such as vitamin A (carotene) and C, in food and fodder crops. For good fertility, grazing animals require Mn concentrations that are about double those required for optimal grass growth. Therefore, a good supply is required in order to obtain full-sized products, as in the case of citrus fruits. Compared with Cu, the optimal range of Zn is large but its toxicity can become a problem on soils with excessive Zn. An excess of chloride can aggravate salinity problems, adversely affect salt-sensitive crops and lower the quality of crops such as potato, tobacco and grapes.