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Due to cultural differences order viagra professional 100mg visa, nity hospital cheap viagra professional 50 mg without a prescription, our day care center is the frst institution providing these opportunities may be perceived as a struggle purchase online viagra professional. Ma- suggest the importance of skills training for adolescent refugees by terial and Methods: In the day care center of Yangming Branch, building their capacities. Taipei City Hospital, Taiwan, we arrange recreational therapy programs to stimulate cognitive functions, gross and fne motor function, and equilibrium. Conclusion: Day care center of Yangming Branch, Taipei City Hospital, Taiwan, a N. According to our experiences, recreational therapy can help icine, Kuala Lumpur, Malaysia, 3University Malaya, Rehabilitation disabled dementia patients improve or maintain their functional Medicine Department, Kuala Lumpur, Malaysia and psychological status. The authors believe that the programs can apply not Introduction/Background: Diabetic Charcot foot can cause gross only to hospital-based day care center, but also in non-hospital- structural deformities of the foot and ankle, and subsequent skin based day care centers. Chung have equal study is to explore complications of diabetic charcot foot in particu- contribution to this poster. Moridnia 1Shahid Beheshti University of Medical Sciences, Clinical Re- mortality rate during the follow-up period was 15. The mean survival time based on Kaplan- Maier Survival Analysis search Development Center of Shahid Modarres Hospital and is 44. The remaining 83 alive sample population Physical Medicine and Rehabilitation Research Center, Tehran, (84. Conclusion: Recurrent new philosophy which tries to lead clinical services to effective and ulcer in Charcot foot patients has high predilection towards limb advantageous ways with the least side effects and errors. Members of faculty, participants who referrals from all states in Malaysia for intensive spinal rehabilita- had attended workshops and physicians who spent more time on tion program or other specialised rehabilitation programs that are research and article review had more knowledge (p=0. Hence, epidemiology data on spinal cord 3 most common sources used for research were PubMed, Google injured patients that was analysed in this study should represent scholar and Cochrane, respectively. Material and Methods: cal practice, the most common source used was reference books Data on all new patients admitted to Spinal Rehabilitation Ward in (86. Analysis was done on the incidence, with getting access to associated databases and lack of suffcient age, gender and level of injury. Results: From Aug 2014 until Nov activity in judging and analyzing related articles. Age group of the studied population are as shown in with its concepts and applications. It may also of benefts for effcient resource allocation for the rehabilitation management of spinal cord injured 1Thomas Jefferson University, Rehabilitation Medicine, Philadel- patients in Malaysia. Material and Methods: The authors reviewed a sample of 220 discharges from J Rehabil Med Suppl 55 Poster Abstracts 237 Thomas Jefferson University Hospital rehabilitation unit readmit- to prevent absenteeism due to sickness. Readmissions were categorized as: (1) from the reha- questionnaire focusing on the organizational setting and its impact bilitation hospital to the acute hospital or (2) from the community on employee wellbeing – reported as mental energy, work-related to the acute care hospital. The questionnaire measures good into categories to provide meaningful information to implement and poor work environment factors to help managers improve or- policies to minimize readmissions. The questionnaire was validated qualitatively plete management, (2) recurrences, and (3) development of new and quantitatively. Cases with new conditions: thors followed a company undergoing organizational change and 36 (73%. Cases with ers uncertain about employee mental status can measure employee new conditions: (54%). Cases with incomplete care or recurrences: wellbeing easily and cost effectively to prevent illness. Conclusion: (1) Most of the cases were readmitted to created a method, statistically evaluated, to proactively identify acute hospitals before completion of their rehabilitation hospital good and poor work Environments to promote healthy co-workers. Japan, 2Fujita Health University, School of Medicine, Toyoake, Hashemi2 Japan, 3Fujita Health University Hospital, Department of Reha- 1 bilitation, Toyoake, Japan, 4Fujita Health University Banbuntane Physical Medicine and Rehabilitation Research Center of Shahid Beheshti University of Medical Sciences and Clinical Research De- Hotokukai Hospital, Department of Rehabilitation, Nagoya, Japan velopment Center of Shahid Modarres Hospital, Physical Medicine 2 Introduction/Background: Previous studies have shown that toe and Rehabilitation, Tehran, Iran, Physical Medicine and Reha- clearance during the swing phase affects the risk of tripping; this bilitation Research Center of Shahid Beheshti University of Medi- is considered a predominant cause of falls. In healthy subjects, toe cal Sciences, Physical Medicine and Rehabilitation, Tehran, Iran, clearance is obtained mainly by lower limb movements. However, 3Arak University of Medical Sciences-Vali-Asr Hospital, Physical in stroke patients, the compensatory movements are more important Medicine and Rehabilitation, Tehran, Iran in obtaining toe clearance. The purpose of this preliminary study is to clarify the system of obtaining toe clearance in stroke patients in Introduction/Background: Trend to non surgical treatments in mus- comparison to healthy subjects. Material and Methods: Thirteen pa- plications and studies in Iran have been started about 15 years ago. A motion analysis system, the Kinema- in musculoskeletal disorders in Iran from 2000 and 2015. Material Tracer® (Kissei Comtec, Nagano), was used for the kinematic anal- and Methods: A review of literatures in Google scholar, PubMed, ysis of the gait. Then was conducted to fnd the difference between the patients with hemi- studies which were related to musculoskeletal disorder were selected. The studies peaked in 2015 when 14 literatures by circumduction, and the elevation of the pelvis by the unaffected were published. About one third of the all studies were randomized limb were signifcantly greater (2. The component analysis 817 of the toe clearance may help targeted rehabilitation to improve toe clearance and potentially reduce the risk of falls. The Swedish Social Insurance Agency was able to decrease sick days in the period between 2000 and 2010 but K. O’Riordan2 sick days are rising again in Sweden, mostly due to psychologi- 1Singapore General Hospital, Rehabilitation Medicine, Singapore, cal problems among women and partly due to their work environ- Singapore, 2Changi General Hospital, Rehabilitation Medicine, ment. Thompson1 research involving the perceptions of patients and their family to- 1Broadgreen Hospital, Phoenix CentRe for Rehabilitation, Liver- wards inpatient rehabilitation and our clinical experience seemed pool, United Kingdom, 2Cheshire and Merseyside Rehabilitation to suggest that a substantial number may view rehabilitation as a Network, Rehabilitation Medicine, Liverpool, United Kingdom passive extension of hospitalisation merely to prolong rest or to allow the organisation of discharge plans. The aim of this study Introduction/Background: Article 5 of Human Rights Act states that is to garner objective data to confrm the extent of these passive ‘everyone has the right to liberty and security of person. Supreme Court judgment in Mar 2014 made these perceptions by focusing on specifc aspects of patient edu- reference to ‘acid test’ to see whether a person is being deprived of cation, with an ultimate goal of improving the active involvement liberty, which consisted of two questions: Is the person subject to of the patients and their families as part of the rehabilitation team continuous supervision and control? Material and patient and one nominated family member, both at the time of Methods: — Retrospective study, Jun 2014 to Oct 2015 carried at admission and at discharge. The purpose of kistan, 2Physical Medicine and Rehabilitation Rehabilitation Hos- this study was to clarify the effects of the use of handrails on pital, Rehabilitation Hospital- King Fahad Medical City, Riyadh, time-distance factors during the treadmill-walking of hemiple- 3 Kingdom of Saudi Arabia, College of Physicians and Surgeons of gics. The time after onset was 1074±1104 Introduction/Background: Pakistan is a low resourced country with days. A KinemaTracer® three-dimensional motion analysis sys- an evolving health care system. For statistical analysis, a on Medline, Google scholar, Science direct and Springer link with Wilcoxon Matched-Pairs Signed-Rank Test was used to compare key words rehabilitation; history; Pakistan; disability ; rehabilita- the two conditions of walking. Results: The stride length and step tion medicine; physiatrist; physiatry ;developing countries and chal- length of both sides were signifcantly longer and the step widths lenges (2000–2015; English language only). Single sup- in Pakistan were approached for sharing their experiences and iden- port time and the ratio of the single support phase in the gait cycle tifying the challenges they faced while establishing this specialty.

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He points out that personality disorder does not disappear when an Axis I condition erupts buy cheap viagra professional 100 mg on-line. Freudian analytical theory recognised certain psychosexual stages in personality development with some variation in their timing generic 50mg viagra professional visa. Oral stage First year of extrauterine life Everything revolves about the mouth Results of excesses of gratification or deprivation at this stage: optimism viagra professional 100 mg overnight delivery, pessimism, self-love, demanding nature, dependence, ingratiating, jealousy and envy Anal stage Centres round the anus and toilet training Derived pathological traits: orderliness, obstinacy, stubbornness, frugality, parsimony, ambivalence, defiance, sadomasochism and rage Anal defensiveness is classically found in obsessive/compulsive neurosis Urethral stage Non-Freudian transitional phase Shame resulting from inappropriate urination causes ambition and competitiveness as compensatory devices Phallic phase Child is focused on his genitals 1795 Masturbates and imagines having sexual relations (oedipal ) Experiences anxieties Resolution of oedipal conflict allows development of superego by identification with influential others and externalisation of drive impulses towards constructive ends Latent stage Sexual impulses are quiescent (this is controversial) Child plays mainly with same-sexed partners and learns many living skills Child may develop excessive or absent inner controls Genital (adolescent) stage Intensified libidinal drives Old conflicts reopened and must be resolved to achieve mature sexual and adult identity 1795Oedipus, a character in a play by Sophocles. Later theorists have put greater emphasis on the shaping influences of extra-psychic factors, such as interpersonal relationships, and socio-cultural influences. For example, parental deprivation causes dependency, struggles with parents leads to obsessive-compulsive traits, and parental eroticisation and competition contribute to hysterical traits. Social learning theory looks at the behaviours that we acquire in our attempts at coping with life. This results from being able to draw on a ‘mental representation’ or internal image of 1797 reliable parental figures. Harlow demonstrated that monkeys separated at birth from their mothers become behaviourally disturbed, impaired sexually, poor socialisers, and rejecting of, and aggressive towards, any offspring that they may bear. In most cases of personality disorder it is probably true that problem behaviours accrue gradually through repetitive learning experiences and, contrary to popular experiences, single experiences only account for a small percentage of cases. In the case of borderline personality disorder it has been argued that it may arise from the lack of constants like customs and values in modern society. Adults then reflect the contradictory and changing customs and beliefs of contemporary society and are left without a feeling for a ‘core’ to their being: ‘the great unreared’. Evolutionary necessity theory states that personality disorder depends on context, i. Allman, 1994, Weiner, 1999) Situationist theory stresses the importance of environment in behaviour determination, e. Everyone has a unique life experience and personality can only be understood from knowledge of that experience (idiographic). The American psychologist Abraham Maslow (1908-1970) believed that we strive to reach the highest level of personal functioning and he wrote about climbing a pyramid of personal integration. Personality was a reflection of self-image and interactions with other people and the environment. Reflecting back what has been said by the patient by the therapist allows recognition of alternative views of perceived problems. The therapist’s role involves providing unconditional positive regard for the client and reacting in a warm, empathic and genuine way. The pre-conventional level (up to 6-7 years) is one of self- interest and obedience aimed only at avoiding punishment or receiving a reward. The conventional level (starts at about 6 years) is characterised by an appreciation of the importance of conforming to rules, 1796 While Ronald Fairbairn (1889-1964) coined the term ‘object relations’, Melanie Klein (1882-1960) is the person most associated with the ‘theory’. He believed that insecure attachments formed early in childhood left a person vulnerable to develop psychopathology, even a disorder of personality. A child who is emotionally deprived or abused in some way may employ defences that are meant to fix or stabilise, but end up inducing dysfunction. Donald Winnicott (1896-1971) wrote of the false self: the child who has unempathic, traumatising parents has to accommodate to such an environment. The capacity to survive in the physical absence of the mother is developed by the 4-7-year-old by relying on the internalised caregiver, itself a product of good enough parenting. Heinz Kohut (1923-81) stated that healthy development flowed from internalising empathic parenting in order to be capable of self-soothing. This type of reasoning has been seen as important in adolescence and as the most common type of reasoning in adults. In the post-conventional level, said to be the highest form of moral reasoning, one understands the complexity (shades of grey) of values and rules and appreciated ethical principles. We act in accord with our self-image and repress feelings that are not in keeping with this. The perceived distance between the self and the ideal self, if wide, causes anxiety. An interesting phenomenon in psychiatry is seen when two men go on strike from work: the busy, enthusiastic worker becomes anxious or depressed whilst the lazy man relaxes. Similarly, the breaking of a leg means more to a national cycling champion than to a loafer. It may be that type A individuals are highly defended and that work allows them to avoid neurotic problems. Genetics: Most measurable aspects of personality appear to be at least moderately heritable. Proposed linkage between D4 dopamine receptor gene alleles and novelty-seeking has yielded mixed results. Instead, one genetic factor reflected broad vulnerability to personality disorder pathology and/or negative emotionality. The two other genetic factors more specifically reflected high impulsivity/low agreeableness and introversion. In other words, the tendency to clustering may be due to environmental experiences. Personality of psychiatrists: There is some evidence that the personality and social attitudes of psychiatrists may, at least in part, influence their choice of treatment modalities, e. Features of burnout Loss of humour Persistent sense of failure Anger, irritability Marital conflict Clock watching Increasing resistance to go to work each day Reluctance to see patients Increased use of psychotropic drugs Sleep disorders Accident proneness Minor ailments 1798 Described originally in 1974 by Friedman and Rosenman. Notes on personality tests1801 1801 Modern tests of personality and behaviour are often divided into objective (responses are objectively scored and interpreted according to normative data) and projective (asked to give meaning to unstructured test stimuli [e. The Lubin checklist of psychopathology looks for feeling tone - various adjectives are ticked off. Questionnaires are best used with an intelligent group because the questions are often difficult to decipher. The Firo-B (Schultz) looks at characteristic ways of interacting with people, such as whether we move toward or away from them. Included are 4, 11, 5, and 2 validity, clinical, treatment, and 2 interpersonal scales respectively. One looks at pictures and says what is happening now and what might occur in the future. The Rorschach (Hermann Rorschach, Swiss psychiatrist, published his test in 1921) consists of ten cards - the famous ink blots. These tests, like all other tests, should never be interpreted in isolation from an appraisal of the whole case by the clinician. Eysenck (1994) believes that projective tests lack validity, that there are too many possible reasons for each choice of response, and that these tests attempt the impossible, i.

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Second viagra professional 50mg discount, even if we can Wnd a set of values and norms based on these values that can be globally accepted purchase viagra professional 50mg on line, we do not pay enough attention to their promotion in practice – what are the most accept- able means to promote the shared values and norms in particular cultural contexts? Liberalism and conflicting interests in medical decision-making When we talk about multicultural issues in maternal–fetal medicine buy cheap viagra professional 100mg, we often start by setting up a polarization between two quite diVerent bioethical frameworks. These approaches are, on the one hand, universalism, which focuses on universal human rights, and on the other hand, relativism, which emphasizes the relativity of cultural belief and value systems. As long as these polarizations remain, there is a tendency to create two opposite bioethical positions – that is, universalist liberal individualism and relativist com- munitarian collectivism. Bioethical thinking in Western pluralist and multicultural democracies is typically based on liberal concepts of justice, demanding the universalization of such individualist values as respect for individual autonomy, protection of individual rights and the promotion of equality and tolerance. On the other hand, this means that we need to let individuals decide on the way they want to live their lives and what kind of cultural identity to maintain. In other words, neither the state nor another individual is allowed to tell somebody what kind of life is ‘the good life’ (Rawls, 1971, 1993; Hellsten, 1999: pp. In a modern pluralist society, we are asked to tolerate diVerent lifestyles and respect diversity in cultural backgrounds within the liberal universalist ethical framework. Even within a liberal framework there are limits to tolerance – diVerences in beliefs and lifestyles can be accepted only if they do not harm someone else or violate someone else’s rights. In modern pluralist society, the most diYcult ethical and multicultural issues are usually those involving conXicting rights and interests of diVerent individuals. In maternal–fetal medicine, for example, we may sometimes disagree about whose rights have the priority – a mother’s rights or her future child’s rights. For instance, whilst the proponent of abortion defends women’s auton- omous choice as a moral agent and their right to control their own body, the opponent may believe (on religious or other grounds) that the fetus is already a moral person and thus has rights that have to be taken into consideration. In most cases of maternal– fetal medicine this would often be the choice between respecting a pregnant woman’s right to decide what happens to her own body and protecting an innocent child from avoidable harm and damage. Besides abortion issues, rights and interest may also conXict when the woman’s actions and lifestyle (drugs, tobacco smoking, alcohol, sexually risky behaviour or unprotected sex) may directly or indirectly jeopardize the health of the fetus (Matthieu, 1996: p. However, in general these disagreements can usually be debated – if not always conclusively resolved – within a shared ethical framework that in itself accepts that all individuals have some universal and equal rights. From the universal protection of human rights to ‘laissez-faire ethics’ When medical decisions are made within a Western liberal bioethical frame- work, the Wrst ethical guideline is that individual rights should always be protected, which takes priority over promotion of the common good. The core guideline in the promotion of equality is that individuals are treated as equals despite Multicultural issues in maternal–fetal medicine 43 their diVerences – whether we talk about random and natural diVerences (diVerences that individuals cannot themselves choose but are born with) such as gender, race and ethnicity, or we focus on the diVerences in people’s choices concerning their values, ways of living or cultural identities. Particularly in this time and age, when tolerance is in general promoted and the plurality of belief systems, value choices and cultural identities appears to have some intrinsic moral value, there is plenty of room for uncertainty about how best to respect autonomy within diVerent social settings and cultural contexts. The problem is that the liberal concept of justice, in its universal request for respect for individual autonomy, tends to ignore social inXuences and community pressures. Thus, while those of us who have been socialized with the Western individualist ethical outlook are ready to reject cultural relativism because of its tendency to give a community priority over individual rights, we may still get trapped into relativist reasoning on the individualist level, in the form of subjectivism. Subjectivism can be described as a degenerate form of individualism which turns the universal demand for tolerance and individual rights into a laissez-faire ethics and moral indiVer- ence, leading in the end to incapacity to make moral judgements (Hellsten, 1999: pp. Despite its harmful physical eVects, this tradition is still practised in various communities around the world; sometimes it still exists even within modern, multicultural society, practised by members of tradi- tional cultures who claim they are merely using their right to maintain their particular cultural identity. Female genital mutilation in its various forms (circumcision proper/sunna, excision, inWbulation) has such immediate dangers to a woman’s health as haemor- rhage and shock from acute pain, infection of the wounds, urine retention and damage to the urethra or anus. Gynaecological and genitourinary eVects include haematocolpos, keloid formation, implantation dermoid cysts, chro- nic pelvic infection, calculus formation, dyspareunia, infertility, urinary tract infection and diYculty of micturition. Obstetric eVects are perineal lacer- ations, consequences of anterior episiotomy, for example blood loss, injury to bladder, uretha or rectum, late urine prolapse, puerperal sepsis, delay in labour and its consequences, for example vesicovaginal and rectovaginal Wstulae or fetal loss. In many cases it is not only the community and/or parents who insist on maintaining the practice; the young women and girls themselves may appear to accept it willingly, even ask for it. In general, however, it is globally recognized that this practice is maintained by social coercion and pressure – mothers are afraid of social ridicule and rejection by their communities. Traditional societies and cultural relativism Subjectivist reasoning was a result of apparently conXicting demands within the liberal concept of justice, which, on the one hand, demanded that we give Multicultural issues in maternal–fetal medicine 45 the rights of individuals priority over any cultural claims, and on the other hand, allowed individuals the freedom to choose their cultural identities. After all, sometimes it is diYcult to know exactly when some lifestyles or cultural identities are autonomously chosen, and when they are the result of strict socialization and indoctrination. At least in a pluralist society, we can plausibly argue that immigrants who choose to leave their country for whatever reason and live within a liberal society, also have to be ready to adopt the norms of their new home country. Particularly if they have left their own country because of its political intolerance or disrespect for individuals’ lives and rights, they should be more than ready to do away with the traditions which themselves violate individuals’ integrity. Finding a framework for ethical agreements becomes more complicated, however, when health care professionals themselves cross borders and work in a country with diVerent value and belief systems from their own. In such a situation relativism lurks behind every corner – in a curious way, the degeneration of liberal individualism into subjectivism gets support from collectivist relativism. First, as discussed above, the fear of paternalism easily leads into subjectivist reasoning and disregard of the special needs and particular social context of an individual. While universalization of values may sound justiWed in theory, in practice Westerners have often been accused of too easily disregarding the rationality of ‘primitive people’, their traditions and their choices of values and norms. The fear of paternalism still makes many liberals wonder whether interfering in an alien culture’s practices is in itself a violation against the universal demand for tolerance and moral autonomy. Second, since some communities protect traditional practices by appealing to the relativity of the cultural norms and to the human rights principles of freedom and non-interference, liberal individualism appears to be merely one ethical outlook among many other ones. Third, since the attempts to change particular practices might actually end up harming rather than helping individual members of the given community, some health care professionals may feel that it is better not to get involved at all. Women’s health in a patriarchal society When working in an international environment, health care professionals may notice that the liberal framework of universalist individualism does not appear to suYce in solving the ethical problems they face in their daily work. Hellsten Particularly when Western medical knowledge and technology is applied in developing countries with more collectivist cultural practices, there can often be clashes between diVerent value and belief systems. This is especially evident in maternal–fetal medicine and reproductive health care, which must Wrst take into account the special needs of women, and secondly Wnd a way to satisfy these needs appropriately in diverse circumstances. Due to social inequality, discrimination and direct violence against women in many parts of the world, mere medical care is not enough to advance maternal–fetal care and reproductive health. In order to improve the overall situation, health care professionals have to identify the symptomatic social causes of the physical problems, such as women’s low position within their society. Particularly in patriarchal societies the questions of individual rights and gender equality become central, because in these societies the protection of women’s health is not a high priority. In order to explicate the relation between the issues of culture, the issues of human rights and the issues of women’s health, I want to take a look at some concrete patriarchal cultural traditions which eVectively hinder the advancement of women’s health care in many traditional communities. The principal duty of a woman in such a society has historically been to bear her husband’s children (particularly sons) and to serve as the foundation of the family. The cost to women’s health of discharging this duty is often unrecognized, and women’s and children’s ill health is still often explained through fate, destiny and divine will, rather than through the neglect of reproductive health services and social injustice (Cook, 1995: p. For instance, in the Tanzanian coastal region one such tradition is the ‘teaching of life skills’, which requires that girls stay indoors (usually in small and dark mud huts) for between three months and three years.

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Diseases of the motor end plate include myasthenia gravis and its related condition Lambert–Eaton myasthenic syndrome cheap 100mg viagra professional fast delivery. Tetanus and botulism are bacterial infections in which bacterial toxins cause increased or decreased muscle tone generic viagra professional 50 mg with visa, respectively order viagra professional 100 mg without prescription. Myasthenia gravis is an autoimmune reaction against acetylcholine receptors; the end-plate potential fails to activate the muscle fibre, resulting in muscle weakness and fatigue. Anti- bodies directed against this protein are found in those patients with myasthenia gravis who do not demonstrate antibodies to the acetylcholine receptor (sero-negative). Botulinum toxin is both a medication and a neurotoxin, produced by the bacterium Clostridium botulinum. It can be used to treat muscle spasms, and is sold commercially under various names (Botox, Dysport, Myobloc, etc. They are multi-protein complexes composed of three different filament systems: • The thick filament system, which comprises myosin protein, connected from the M-line to the Z-disc by titin (connectin), and myosin-binding protein C, which binds at one end to the thick filament and at the other to actin. Sarcomere Z-line Z-line thin filament thick filament H-zone I-band I-band A-band Figure 17. The relationship between the proteins and the regions of the sarcomere are as follows: • Actin filaments are the major component of the I-band and extend into the A-band. Titin (along with its splice isoforms) is the biggest single highly elasticated protein found in nature. It provides binding sites for numerous proteins and is thought to play an important role in the assembly of the sarcomere. Focal adhesions (in muscle often referred to as costameres) are regions that are associated with the sarcolemma of skeletal muscle fibres and comprise proteins of the dystrophin–glycoprotein complex and vinculin–talin–integrin system. Focal adhesions play both a mechanical and a signalling role, transmitting force from the contractile apparatus to the extracellular matrix in order to stabilise skeletal-muscle fibres during contraction and relaxation. Several focal adhesion constituent proteins have been shown to be defective in muscular dystrophies and cardiomyopathies. Focal adhesions are large macromolecular assemblies through which both mechanical force and regulatory signals are transmitted. They can be considered as sub-cellular macro- molecules that mediate the regulatory effects (e. Focal adhesions serve as the mechanical linkages to the extra- cellular matrix, and as a biochemical signalling hub to concentrate and direct numerous signalling proteins at sites of integrin binding and clustering. Integrins are cell-surface receptors that interact with the extracellular matrix and mediate various intracellular sig- nals. Vinculin is a membrane-cytoskeletal protein in focal adhesions that is involved in linkage of integrin adhesion molecules to the actin cytoskeleton. Although dystrophin is not required for the assembly of focal adhesions, its absence in humans and mice leads to a disorganised focal adhesion lattice and disruption of sarcolemmal integrity. Deficiency of dystrophin is the main cause of muscular dystrophy; mutation in the gene causes Duchenne muscular dystrophy, a severe recessive X-linked form of muscular dystrophy characterised by rapid progression of muscle degeneration, which eventually leads to loss of ambulation and death. This affliction affects 1 in 3500 males, making it the most prevalent of muscular dystrophies. A different mutation of the same gene causes defective dystrophin, leading to Becker’s muscular dystrophy. Intrinsic cardiomyopathies are generally classified into a number of types, but dilated cardiomy- opathy is the most common form, and one of the leading indications for heart transplantation; approximately 40% of cases are familial, with mutations of genes encoding cytoskeletal, con- tractile or other proteins present in myocardial cells. The disease is genetically heterogeneous, but the most common form of its transmission is an autosomal dominant pattern. When energy levels become too low, muscle weakness and exercise intolerance with muscle pain or cramps may occur. Metabolic muscle diseases that have their onset in infancy tend to be the most severe, and some forms are fatal. Those that begin in childhood or adulthood tend to be less severe, and changes in diet and lifestyle can help most people with the milder forms adjust. It is the only glycogen storage disease with a defect in lysoso- mal metabolism, and was the first glycogen storage disease to be identified. The build-up of glycogen causes progressive muscle weakness (myopathy) throughout the body and affects various body tissues, particularly in the heart, skeletal muscles, liver and nervous system. It is the most common of the various types of glycogen storage disease, but is still considered rare (about 1 in 100 000). Forbes’ disease is one of several glycogen storage disorders that are inherited as autosomal recessive traits. Symptoms are caused by a lack of the enzyme amylo-1,6 glucosidase (debrancher enzyme). This enzyme deficiency causes excess amounts of an abnormal glycogen to be deposited in the liver, muscles and in some cases heart. The disease typically presents during infancy with hypoglycaemia and failure to thrive. Intracellular carnitine deficiency impairs the entry of long-chain fatty acids into the mitochondrial matrix. Consequently, long-chain fatty acids are not available for β- oxidation and energy production, and the production of ketone bodies (which are used by the brain) is also impaired. Regulation of intramitochondrial free CoA is also affected, with accumulation of acyl-CoA esters in the mitochondria. The adult myopathic form is the most common inherited disorder of lipid metabolism affecting the skeletal muscles; it is also the most fre- quent cause of hereditary myoglobinuria. Symptoms of this disease are commonly provoked by prolonged exercise or periods without food. Classic Tarui’s disease typically presents in childhood with exercise intolerance and anaemia. A late-onset variant man- ifests itself during later adulthood with progressive limb weakness without myoglobinuria or cramps. Symptoms may include anaemia, enlargement of the spleen, mental retardation and epilepsy (seizures); more rarely, weakness, exercise intolerance, muscle cramps and episodes of myoglobinuria occur. Symptoms include exercise intolerance, cramps, muscle pain and sometimes myoglobinuria. Myoglobinuria is the presence of myoglobin in the urine, often associated with rhabdomy- olysis. The destruction of the muscle leads to the release of the breakdown products of damaged muscle cells into the blood stream; some of these, such as myoglobulin, are harmful to the kidney and may lead to acute kidney failure. It is a dynamic structure that maintains cell shape, protects the cell and mediates cellular motion and intracellular transport, as well as cell division. Eukaryotic cells contain three main kinds of cytoskeletal filament: • actin filaments/microfilaments • intermediate filaments • microtubules. They are mostly concentrated just beneath the cell membrane, and are responsible for resisting tension and maintaining cellular shape, and participating in cell–cell and cell–matrix junctions; in these latter roles they are essential to intracellular signal transduction processes. They are also important for cytokinesis (division of the cytoplasm in mitosis) and cytoplasmic streaming in most cells. Like actin filaments they function in the maintenance of cell shape by bear- ing tension. Intermediate filaments organise the internal tridimensional structure of the cell, anchoring organelles and serving as structural components of the nuclear lamina (a dense fib- rillar network inside the nucleus) and sarcomeres.