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By: William A. Weiss, MD, PhD
- Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
Primary air pollutants (discussed later in the chapter) are those emitted directly by sources of pollution finast 5 mg without a prescription hair loss 1 year after childbirth. Secondary air pollutants are those generated from atmospheric chemical reactions among primary pollutants buy cheap finast 5mg online hair loss cure two years. The circle indicates the locations of more than half of the deaths that occurred Several natural events produce air pollutants generic 5 mg finast free shipping hair loss from chemotherapy, espe during the killer smog discount finast 5mg without a prescription hair loss men treatment. When Smoke Ran Like Water: Tales of Environmental Deception and the Battle wind storms that spread dust clouds, salt evaporation Against Pollution. The evidence that spurred air pollution research and galva smoke trails can be seen by satellites hovering above nized public health ofcials. In some cases, forest fres are truly natural events, such as when caused by lightning strikes. Sources and Causes when caused by human carelessness, arson, or eforts of Air Pollution to clear vegetation from the land. Volcanic eruptions are another natural source of air What is meant by the term air pollution? Examples are the dust clouds produced by the perfectly clean air?which is not found in the natural eruptions of El Chichon near Mexico City; Galunggung environment, even in the most remote locations such in West Java, Indonesia; and Mount Pinatubo, in the as up in the mountains far away from human activi Philippines. In the laboratory, it is possible to produce clean air Mount Saint Helens eruption spewed forth tons of fne artifcially by using fltration and other methods. However, a 5-year longitudi particles and vapors that arise from natural and nal follow-up study of loggers who were exposed to ash anthropogenic sources. Each liter of air may contain from Mount Saint Helens indicated that the risks of lung thousands of invisible suspended particles and also diseases such as chronic bronchitis and pneumoconio hundreds of invisible vapors; because these constitu sis are minimal when exposure is initially high and then ents are invisible, we are unaware of their presence. Anthropogenic Sources of Air Pollution Numerous sources emit pollutants; these sources As noted previously, anthropogenic sources of air pol can be dichotomized into natural and anthropogenic lution include stationary sources and mobile sources. Among the constituents of air commute to work alone despite the availability of pollution from motor vehicles. Many geograph are sulfur dioxide, particulate matter, greenhouse ically dispersed regions of the United States do not gases. This situation contrasts with developed Euro include heavy metals and toxics such as benzene. Improvements relevant to air quality: volatile organic compounds and include low-sulfur fuels, emission control tech smog (a mixture of pollutants). The following pollution include electrically powered and hybrid discussion presents a detailed examination of these pol vehicles. Lead, once a universal component of gaso than that of on-road vehicles, of-road vehicles such line, has been phased out or is being phased out in most as dune buggies and snowmobiles can add to air pol areas of the world; nevertheless, lead remains an import lution in the areas where they are used. For example, ant environmental contaminant that arises from many they may be a cause of air pollution in national parks sources in addition to air pollution. Found near ground level, ozone in smog stems from a series of chemical reactions among the products of combustion of fossil fuels (including? Components of Air Pollution gasoline) in combination with various chemicals found How do scientists classify air contaminants? Another classifca as the infuence of human activities on the environ tion segregates air contaminants into particles, gases, ment that are hypothesized to have reduced the ozone and vapors. The health efects attributed to ground-level As noted, air pollution is composed of a number ozone include respiratory difculties such as reduced of components; these include solids and gases. Lead (Pb) Leaded gasoline, paint, Can damage nervous Persists in environment; batteries; lead smelters system, immune system, and accumulates in soil, kidneys sediments; can harm plants and animals. Nitrogen oxides are also major compo burning of solid, liquid, and gaseous fuels. Smokers are biles, as well as other fuels such as natural gas, diesel exposed routinely to carbon monoxide from tobacco oil, and coal. Air pollution scientists attribute urban smoke, although this level of exposure is not sufcient ozone, acid rain, and oxygen depletion of coastal waters to cause death. On January 2, Components of Air Pollution 249 2006, an explosion at the Sago coal mine in West Vir mortality, also causes environmental degradation ginia was linked to the deaths of 12 of 13 miners who through the deposition of soot on vehicles, clothing, were trapped deep underground. Such pollutants are known to irritate survivor demonstrated symptoms of severe carbon the eye, nose, and throat. Carbon monoxide has more than class of particles that are called ultrafne (diameter of 200 times more afnity for binding with hemoglo 0. Both are criteria air pollutants, as tion of carbon monoxide and hemoglobin is called noted previously. High levels of carboxyhemo ticulate matter include respiratory system irritation, globin interfere with the capacity of blood to trans lung damage, and development of bronchitis. Some of the fine include diesel exhaust from trucks and buses; smoke particles may contain liquid acid condensates and from incineration of garbage, wastes from crops, and toxic heavy metals. Particulate matter, which smog-related deaths annually in the United States;19 has been linked to lung damage, bronchitis, and early not all agree that the figure is this large. Volatile chemicals evaporate and thus escape of particulate pollution in the developed regions of the into the air easily. In northern Europe, Scandinavian construction materials, and solvents such as benzene and countries. Tese demonstrated levels that were roughly nine times the then mix with water and other materials before fall standard. A tem perature inversion is the reverse of the usual situation in which the air closer to the surface of the earth is warmer than the air in the upper atmosphere. Continuing release acid rain settles on the earth, creating abnormally high of smog-forming pollutants from motor vehicles and levels of acidity that are potentially damaging to the other sources during an inversion exacerbates air pol environment, wildlife, and human health. A When the cost of fuel for vehicles is high and as oil meta-analysis reviewed studies of the possible etio shortages persist, the use of diesel engines will tend to logic role of occupational exposure to diesel exhaust grow in popularity because of their greater energy ef ciency and endurance. Residents (both children and adults) of urban Values Health Concern Colors areas may be exposed to diesel exhaust from motor vehicle trafc.
Individual gain/loss of Currently the storage of the resulting image is a gene expression can be viewed with both temporal stumbling block to order 5mg finast hair loss cancer the routine use of digitization discount 5 mg finast overnight delivery hair loss cure - medicinal plants. Additionally a controlled heat ware can be used to buy discount finast 5mg line hair loss dermatologist scan at multiple levels 5 mg finast fast delivery hair loss cancer, allow application is needed to denature and anneal the ing z-stacking? of images to duplicate the effect of nucleic acids, making automation the obvious choice. This system fully automates the run Whichever way the images are produced, the abil from dewax to final coverslip, producing up to 100 ity to view a sample in high resolution on a computer slides per day. The latter 0 They cannot be left in another office or at features individual slide drawers and continuous another site. This results in can access it in minutes and do side by side com potential delays and the added risk of slides being parisons with the up to date case. With automated archiving there would be Automated block filing/ archiving no need to relabel these specimens with additional numbers. In the first, the block is scanned and a computer efficiency and consolidate resources, the scalability system identifies the next available position for stor of many processes currently carried out seems likely age. The block is then archived in this position, either to be placed under increasing pressure. The second Increasing the size of a laboratory and streamlining approach, such as that seen in the Thermo Fisher Arcos its workload without also investing in developing the system is to mount a scanner above the block file tray, infrastructure underpinning the service, often results and scan whole racks of barcoded blocks into file. It has been archive database software then stores the location of known for some time in many fields that the scalabil each block (Thermo Scientific, 2016). Not only does this reduce tology process from receipt to reporting are already the time spent sorting and organizing the archive, it on the way, and slide scanning is developing the future of automation in histology 151 towards a point where it will soon be conceivable it is often introduced in a fragmentary fashion as to use and store digital images in place of glass funding becomes available and equipment requires slides. This piecemeal introduction can be ogy, voice recognition and macroscopic imaging can particularly inefficient and frustrating when it is all be combined and made available to the reporting considered that the largest benefits of automation pathologist alongside the digital slide to produce an are realized when each element is linked together to integrated reporting platform which can be remotely form a cohesive system. It is the role of the laboratory management team the laboratory process itself can be streamlined, to bear in mind the holistic vision and overall objec with sample tracking, automated transcription and tive of the department when considering such remote test requesting increasing patient safety, replacements to ensure unified and efficient adop whilst reducing the workload. Each compo Reproducibility, consistency and reagent manage nent must be selected to both add value in itself, but ment can be improved and recorded through use also represent a step towards a long-term goal of an of automated processing and staining platforms. Automation as a service develop these techniques can produce audit data which can ment is dauntingly expensive in terms of resource be used to identify bottlenecks, target inefficiencies commitment, requiring large amounts of funding and monitor workflows visible in real time on dash and/or time to be invested in the process. However, the uptake of these technologies mation in histology makes it a significant option for has been slow in many laboratories and must not be a modern laboratory. References the automated instrumentation and workflow patterns must work synergistically together and Adler, D. Ntt=Artisan%20Link%20Pro%20 dardization and release of staff from making these Special%20Staining%20System [Accessed 29 Nov. The ratio of cells to intercellular endoderm are divided by a germ cell layer, the substance and the primary function varies from mesoderm or mesenchyme. Connective tissues and substance, its main function being strength and sup muscle develop from the mesenchyme. The cell types of connective tissue include fibro cell of the entire series, the embryonic mesenchyme blasts, mast cells, histiocytes, adipose cells, reticular cell, is rarely found in adults. Many Connective tissue of these can be analyzed using immunocytochemical techniques (see Chapter 19). This is one of the four tissue types found in the body, From the histochemistry perspective, connective the term coming from the Latin connectere? meaning tissues are usually considered as intercellular sub to bind. Most types of con non-sulfated and sulfated mucopolysaccharides, nective tissue consist of three elements: the cells, the and the formed elements of collagen, reticular fibers fibers and the amorphous ground substance which the and elastic fibers. The nature of the intercellular is based upon their appearance in areolar and loose tis substance varies according to its function. Its microscopic appearance groups: also varies from fibrillar to homogeneous allowing. It is usually not tem, or as large bundles of fibers clumped together visible by light microscopy. Ultrastructurally, genetic control, each reflecting slight variations in reticular fibers are loosely packed fibrils surrounded the? The argyrophilia of reticular fibers is due to the proteoglycan content of the fibers and is not depen Type I dent upon the proteins of the fibrils themselves. The fibrils show the characteristic 64 this has been characterized in structures identified nm axial periodicity. It is gen banding? in Type I collagen is thought to be due to erally accepted that it does not form fibers or fibrils the lack of interference from interfibrillar ground visible with light microscopy. Type V collagen is produced in small quantities by a wide range of cells which include con nective tissue, endothelial and some epithelial cells. It remains in close contact with the cell surface and is thought to be involved in the attachment of cells to adjacent structures and the maintenance of tissue Fig. Type I collagen stains strongly with acid dyes due to the affinity of the cationic groups of the proteins Elastic fibers for the anionic reactive groups of the dye. Collagen the elastic system fibers oxytalan, elaunin and elas may be demonstrated more selectively by either tic have a fibrillar, amorphous, or mixed structure compound solutions of acid dyes. They provide the bulk of the supporting membranes are interrupted by minute holes called framework of the more cellular organs. These liver and lymph nodes, where they are arranged in fenestrae permit diffusion of materials through the a three dimensional mesh network providing a sys otherwise impermeable membrane. The proportions of the two components alter with the age of the fiber and probably the age of the subject.
They showed striking results with over 80% of randomized 5 mg finast with mastercard hair loss uterine cancer, controlled portion of the trial was limited patients discount finast 5 mg free shipping hair loss in men treatment, with 55 buy 5mg finast mastercard hair loss in men jackets. Summary results of eligible studies of mechanical lumbar disc decompression with nucleoplasty 5mg finast with amex hair loss cure food. Methodological Quality Number of Significant Pain Relief Results Study Scoring Participants > 12 mos. An update of the systematic assessment of mechanical lumbar disc decompression with nucleo plasty. Using sessed 396 patients with lumbar disc herniation related a cannula placement similar to that used for a standard pain and no improvement after previous conservative discography, less pertinent scarring and less postopera clinical treatment. The results showed that among all tive fibrosis may be expected with this device (1230). In this assessment of percutaneous mechanical disc decompression using the volumetry, they found that average preinterventional Dekompressor device (1232) identified 3 nonrandom nucleus volume was 0. All studies were tional volume reduction in the nucleoplasty group was reasonably rigorous in reporting pain relief and the use significant at 0. The results suggested that, even though the in cluded that nucleoplasty achieved volume reductions of vestigators reported pain relief, there was a lack of rigor 14. Consequently, nucleoplasty of other health care resources and physical functioning. The review (21) and one comprehensive review (1232) were remaining evidence is dependent on observational assessed. The number of observational studies meeting 3, compared to 2 in previous systematic evaluations inclusion criteria has increased to 14 with one large (1230,1233,1235). The available were rather strict, in that at least 50 patients and one literature on Dekompressor illustrates the common year follow-up was required. The device removes a predetermined may have been more objective if the assessment had in amount of disc material from the herniated disc, reduc cluded some form of functional improvement measure. However, this study failed to meet inclusion criteria, were published for 42 patients (54 treatment levels). Follow patients achieve marked improvements that are sus up data at 12 months were obtained for all patients. Only one study reported complete relief in 14% procedure, 61 patients (95%) regularly used opioid or of patients (1231,1233). Other studies reported only the nonopioid analgesics; after one year, 51 patients (80%) proportion of patients reporting significant pain relief, were able to reduce analgesic use. The authors Because of their observational nature, the studies also concluded that, when standardized patient selection lack a control group and randomization, and are po criteria are used, treating patients with radicular pain tentially biased by the investigators. Consequently, the associated with contained disc herniation using Dekom true effectiveness of Dekompressor may be less than re pressor can be a safe and efficient procedure. Although the study by Amoretti et al (1235) published results of a clini Alo et al (1231,1233) rigorously reported pain-related cal follow-up of 50 patients treated by percutaneous data, it was sponsored by the device manufacturer and lumbar discectomy using Dekompressor. Although not involved the inventor of the device, again raising ques a blinded and randomized study, the data collection tions about potential bias (1232). Other dalities) which these patients have basically failed prior exclusion criteria included infection and coagulopathy, to considering Dekompressor, they have no other op as well as pre-operative treatment with morphine and tion except for high-dose opioid therapy. Pain reduction was reported to stabilize after about one duplicate publication (1231,1233), the evidence for 7 days in most patients. Of the patients who responded percutaneous disc decompression with Dekompressor is favorably, 36 out of 50 experienced > 70% relief. These complications associated with intradiscal pro cedures include hematoma; infection, either superficial or associated with abscess; allergic reaction to radiographic contrast or antibiotic; bleeding; and direct needle trauma to spinal nerve with transient or persistent paresthesia and spondylodiscitis (21,22,142,512,521,552, 1137,1140,1149,1154,1158,1162,1165,1166, 1168-1173,1188,1189,1237-1249). Nerve injury can occur from several sources including direct root injury during needle in sertion or from the decompression process if improperly performed. This should be avoid able by ensuring a responsive patient during the entire procedure and listening carefully for radicular/paresthesia complaints throughout. Infection risk can be lowered by the use of a meticulously sterile technique and intravenous or intradiscal antibiotics. Other complications include damage to the adjacent endplate, the development of spinal instability, and/or the potential for disc space collapse with associated progressive degenerative changes. Complications of percutaneous lumbar laser discectomy are classified into intra operative and postoperative complications (1166,1168-1173,1188,1189,1239-1248). The most frequently described complication of percutaneous disc decompression is (spondylo) discitis (1168,1170,1173,1241,1242,1243), both aseptic and septic. Aseptic discitis is the result of heat damage to either the disc or adjacent vertebral endplates (1248). The goal of percutaneous lumbar laser disc decompression is to leave the annulus fibrosis and surrounding tissues S114 Consequently, sion with Dekompressor are similar to complications the extent of heat penetration is to be kept as low as occurring for other percutaneous disc decompression possible (44). Septic discitis can occur as a result of infec modalities involving the passage of an instrument into tion during needle placement (29,932,1165,1238,1249). One critical failure of the Dekompressor probe Another complication is thermal nerve root damage was reported while performing a discectomy at the L4/5 due to heating of the cannula, which represented a level on a 54-year-old patient (1236). The tip was removed surgi fixed cannulae, so this rate is not representative for cally, and the patient recovered without any major percutaneous lumbar laser disc decompression in rou complication.
The images from the two eyes are fused in the cerebrum so that only one image is perceived buy finast 5 mg with mastercard hair loss and hormone x. Binocular vision provides a much more accurate assessment of one object relative to purchase finast 5mg with mastercard hair loss in men 39 s wearhouse coupons another cheap finast 5mg without a prescription hair loss 6 months post partum. Some people with monocular vision may find it difficult to buy generic finast 5mg online hair loss cure 4 feet judge the speed and distance of an approaching vehicle. The retina is divided into the temporal and nasal halves at the level of the fovea centralis. The nerve fibres from the nasal side of each retina cross-over to the opposite side. The nerve fibres from the temporal side do not cross but pass into optic tracts of the same side. They are cylindrical bands running outwards and backwards to end in the lateral geniculate bodies. They consist of the temporal fibres of the same side and the nasal fibres of the opposite side. The fibres of the optic tracts end in the lateral geniculate bodies and new fibres of the optic radiations originate from them. The neuron of the second order is the ganglion cell in the retina, the process of which pass along the optic nerve, optic chiasma and optic tract to the lateral geniculate body. The neuron of the third order takes up the impulses via the optic radiations to the occipital lobe (visual centre). Homonymous hemianopia?There is loss of right or left half of binocular field of vision. Lesions of the occipital lobe often result in homonymous hemianopia with sparing of the fixation area. Site of lesion?Lesions situated on the either side of the optic chiasma destroying the temporal fibres of each retina. It is basically a deprivation phenomenon whereby fixation reflexes are not developed. Retrobulbar neuritis?There is the acute inflammation of the optic nerve situated behind the eyeball. It exhibits protean manifestations such as characteristic spiral visual fields, blinking, blepharospasm, etc. Amaurosis fugax?There is sudden loss of vision due to embolisation of retinal circulation. Gaze-evoked amaurosis?Transient loss of vision occurs in a particular direction of eccentric gaze. Uraemia?It occurs in acute nephritis and chronic renal disease due to circulation of toxins, which act on visual centres. Hysteria?Psychogenic aspect of the disease is often treated but great care is taken to eliminate any organic disease. Lebers congenital amaurosis (retinal aplasia)?It is characterised by reduced visual acuity, head nodding and nystagmus. The neuron of the 1st order in the visual pathway lies in which layer of retina a. Gradual loss of vision commonly occurs in cataract, open angle glaucoma, uveitis maculo pathy, toxic amblyopia, chorioretinal degenerations, optic atrophy, etc. Poor accommodation and conver Habits?Sleep, tobacco and alcohol intake, diet, gence digestion and bowel habits. Position and direction?They are abnormal in cases of squint, exophthalmos, enophthalmos, phthisis bulbi, etc. Section of the upper eyelid showing normal and abnormal position of tarsus and eyelashes vi. A gentle pull on the eyelashes and simultaneous pressure over the skin of the upper lid by index finger or glass rod is given to evert the upper lid. The lower palpebral conjunctiva and fornix are exposed by pulling the lower lid downwards. Cornea?In children and in marked blepharospasm, lid retractor may be used for examination after instillation of local anaesthetic. Common causes Acute conjunctivitis Keratitis Acute and chronic iridocyclitis Acute congestive glaucoma. Deep staining?After instilling the dye the lids are kept closed for about 5 minutes. Curvature and colour?There is thinning, pigmentation and ectasia of the sclera in myopia, staphyloma and blue sclerotics. Tremulousness (Iridodonesis)?Excessive movements or tremors of iris are seen best in a dark room (with oblique illumination) when eyes move rapidly. Pupil Size?Normal size of the pupil is 2-4 mm Anisocoria?Unequal size of both the pupil is called anisocoria Miosis?The pupil is small and constricted Mydriasis?The pupil is dilated Miosis?The pupil is small and constricted due to the action of sphincter pupillae muscle. Afferent pathway?The optic nerve Centre?Edinger-Westphal nucleus in midbrain (third nerve nucleus). Indirect (consensual) light reflex?If light enters an eye, the pupil of the other eye also contracts. The decussation of the nerve fibres in the midbrain explains the mechanism of the indirect reflex. Near reflex (accommodation reflex)?Contraction of the pupil occurs on looking at a near object. Psychosensory reflex?A dilatation of the pupil occurs on psychic or sensory stimuli. Colour?Jet black?Normal, aphakia Grey?Immature cataract White?Mature cataract, retinoblastoma, pseudogliomas, etc. Brown/black?Nuclear cataract, Morgagnian cataract Dislocation into anterior chamber Posterior dislocation Yellowish?Shrunken lens in hypermature cataract.
All providers delivering services to finast 5mg otc hair loss cure hypothyroid young people should be implementing the good practice guidance which delivers compliance with the quality criteria buy 5 mg finast with mastercard hair loss cure 4 sore. There are measurable adverse consequences in terms of morbidity and mortality as well as in social and educational outcomes cheap finast 5mg without a prescription hair loss cure uk. When children and young people who use paediatric services are moving to buy 5mg finast with amex hair loss in men over 60 access adult services (for example, during transition for those with long term conditions), these should be organised so that. All hospital settings should meet the Standards for the Care of Critically Ill Children (Paediatric Intensive Care Society, London 2010). There should be age specific arrangements for meeting Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. They will probably do mainly non-specialised work but may do specialised procedures. They may also do emergency spinal procedures within their commissioning guidelines. If these hospitals are doing a large amount of specialised spinal work then there should be an explanation as to why they are not a hub. A decision can then be taken whether spinal surgery is required and whether this needs to be specialised or not. Areas will develop robust pathways routing these patients to the appropriate hospital for their surgery relative to their varying presentations. Only when spinal hub? hospitals have sufficient elective work to support the on-call service will additional work be commissioned with spinal spoke? hospitals and other providers. For example, a 2-level instrumented spinal fusion +/ decompression may be done for degenerative disease, tumour, trauma or infection and whilst the technical skills may be similar, the pathways of care and service requirements are very different. Therefore in certain circumstances it is important to consider diagnosis above procedure. It is necessary to understand the type of patients who are receiving treatment for spinal conditions and where and how they are accessing this treatment. It has also been considered helpful to cluster types of treatment into a number of broad categories, which indicate which area of specialist care can provide the service. Clinical commissioning groups and specialised commissioning must interface along these pathways. The networks for general spinal work (including primary care) must be co-ordinated with the individual and sometimes differing networks for trauma and cancer. The procedures carried out within each of these sub groups has been reviewed to identify whether they would meet the criteria for a specialised or non specialised service. The detailed procedure coding related to each of these has also been reviewed in order to ensure that the split of activity can be allocated to the responsible commissioner and the results are attached as an annex to this scope. Spinal Deformity surgery: All spinal deformity surgery is classed as specialised for both adults and children. Revision surgery: Revision cervical and lumbar decompressions are non-specialised i. Therefore revision surgery with instrumentation for lumbar fusion for 2 levels or under is classed as non specialised. Cervical, Thoracic and Anterior Lumbar surgery: All thoracic and anterior lumbar surgery is specialised. Cervical surgery includes some procedures which are specialised and some which are not and can be summarised as follows. Interventions for persistent non-specific spinal pain: the following procedures are non specialised. Some specific guidelines have been produced by recognised bodies, including specialist organisations. Spinal Deformity Surgery All spinal deformity surgery is considered specialised in adults and children. Otherwise, the surgical procedures should be considered specialised or non specialised as for their adult spinal surgery. Spinal reconstruction surgery (trauma, metastatic tumour and infection) the spinal management of these conditions is specialised with only biopsy procedures and closed manipulation of fractures considered non-specialised. However, before these non specialised procedures are performed discussion with one of the network specialised spinal centres should occur. The only procedures performed in these conditions which are considered non-specialised in degenerative spinal surgery but should be considered specialised in tumour, trauma and infection are anterior and posterior cervical decompression/discectomy and posterior instrumented lumbar fusion. Curative or potentially curative oncological surgery this is highly specialised work which shall be located in only a small number of centres in England. There needs to be further discussion as to whether these are considered in the Specialised Spinal Surgery Scope or considered in the Specialised Paediatric Neurosciences and Neurosciences Scopes. It follows an extensive review of the international literature and wide consultation with professional groups in New Zealand. The Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain provides an overview of risk factors for long-term disability and work loss, and an outline of methods to assess these. It is based on a systematic review of the best available (Jan 1999 Feb 2002) scienti? Further evidence reviews by the expert panel took place in 1998, 2000 and 2001/2002. This means staying or becoming physically active and resuming usual activities, including work, as soon as possible. If the pain radiates down the leg, below the knee, there is a greater chance that symptoms are caused by a herniated disc.
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