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Congenital long Q-T Restrict from all competitive sports Syndrome (High risk for death) Kugler JP discount viagra vigour 800mg with amex, O’Connor FG: Cardiovascular problems purchase 800 mg viagra vigour free shipping, in Lillegard WA trusted viagra vigour 800mg, Butcher JD purchase 800 mg viagra vigour fast delivery, Rucker KS, (eds. CHAPTER 26 DERMATOLOGY 149 Kugler JP, O’Connor FG, Oriscello RG: Cardiovascular consid- Pyeritz RE: The Marfan syndrome. Am Fam Physician 34:83–94, erations in the runner, in O’Coonor FG, Wilder RP, (eds. New York, NY, McGraw-Hill, Ragosta M, Crabtree J, Sturner WQ , et al: Death during recre- 2001, p 341. Ned Sci Sports Leon AS, Connett J, Jacobs DR Jr, et al: Leisure-time physical Exerc 16:339–342, 1984. Luckstead EF, Sr: Cardiac risk factors and participation guidelines Strong WB, Steed D: Cardiovascular evaluation of the young ath- for youth sports. Manolis AS, Linzer M, Salem D, et al: Syncope: Current diagnostic Tabib A, Miras A, Taniere P, et al: Undetected cardiac lesions evaluation and management. Thompson PD, Funk EJ, Carleton RA, et al: Incidence of death Maron BJ, Araujo CG, Thompson PD, et al: AHA science advi- during jogging in Rhode Island from 1975 through 1980. Med Sci Sports Exerc of the World Heart Federation, the International Federation of 27:641–647, 1995. Sports Medicine, and the AHA Committee on Exercise, Cardiac Villeneuve PJ, Morrison HI, Craig CL, et al: Physical activity, phys- Rehabilitation, and Prevention. Maron BJ, Gohman TE, Aeppli D: Prevalence of sudden cardiac Whelton PK, He J, Appel LJ, et al: Primary prevention of hyper- death during competitive sports activities in Minnesota high tension. Williams PT: Relationship of distance run per week to coronary Maron BJ, Mitchell JH (eds): 26th Bethesda Conference. Arch Intern Recommendations for determining eligibility for competition Med 157, 191, 1997. Am J Cardiol Williams PT: Relationships of heart disease risk factors to exer- 24:845–899, 1994. Maron BJ, Poliac LC, Roberts WO: Risk for sudden cardiac Zeppilli P: The athlete’s heart: Differentiation of training effects death associated with marathon running. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the Sudeen Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American 26 DERMATOLOGY Heart Association. Murkerji B, Albert MA, Mukerji V: Cardiovascular changes in Kenneth B Batts, DO athletes. Niedfeldt MW: Managing hypertension in athletes and physically active patients. Oakley DG, Oakley CM: Significance of abnormal electrocardio- INTRODUCTION grams in highly trained athletes. Paffenbarger RS, Hyde RT, Wing AL, et al: The association of Skin serves as a protective barrier against mechanical, changes in physical activity level and other lifestyle characteristics environmental, and infective forces. Pelliccia MD, Maron BJ, Culasso F, et al: Clinical significance of him or her at risk for disqualification or impede his or abnormal electrocardiographic patterns in trained athletes. Pluim BM, Zwinderman AH, van der Laarse A, et al: The ath- lete’s heart. Powell KE, Thompson PD, Caspersen CJ, et al: Physical activity ABRASIONS and the incidence of coronary heart disease. Priori SG, Aliot E, Blomstrom-Lundqvist C, et al: Task force on Commonly known as rug burn, strawberries, or road sudden cardiac death, European Society of Cardiology. ACNE MECHANICA The use of heel cups, felt pads, cushioned athletic socks, and properly fitted footwear may help to prevent black An occlusive obstruction of the follicular piloseba- heel formation. Athletes should be well Notable exceptions are the persistence of a linear informed and educated prior to the use isotretinoin for black band or streak running the entire length of the severe pustular acne because of the side effects of nail representing a melanocytic nevus or the more muscle soreness, joint pain, and lethargy (Basler, serious involvement of the proximal nail fold in 1989). ATHLETIC NODULES BLISTERS Fibrotic connective tissue (collagenomas) because of Vesicles or bulla filled with either serosanguinous repetitive pressure, friction, or trauma over bony fluid or blood. CHAPTER 26 DERMATOLOGY 151 Bullous blisters should be drained at the edge with a INGROWN TOENAIL small needle leaving the roof of the blister as a pro- tective layer. CHOLINERGIC URTICARIA Cholinergic urticaria is an acetylcholine-mediated, ENVIRONMENTAL INJURY pruritic dermatosis that occurs commonly on the chest and back during exercise or emotional stress (Houston HEAT and Knox, 1997).

Postsurgical pain and associated psychological stress can have negative effects on the immune system and endocrine func- tion that impact on recovery (Kiecolt-Glaser et al order 800 mg viagra vigour with mastercard. Moreover order 800mg viagra vigour mastercard, uncon- trolled nociceptive input may over time result in pathological changes in the central nervous system that could contribute to pain chronicity (e discount 800mg viagra vigour free shipping. This central sensitization phenomenon may help explain findings that greater acute pain severity predicts transi- tion to chronic pain (Murphy & Cornish generic viagra vigour 800mg amex, 1984), and that earlier aggressive management of acute pain may reduce the incidence of postsurgical chronic pain (Senturk et al. Overall, the results just described underscore the fact that effective management of acute postsurgical pain can have a significant impact on outcomes. Adequacy of pain control may also be an important issue to consider with regard to less invasive painful medical procedures. Optimal acute pain control in this latter context may increase tolerability of necessary procedures and impact on willingness to engage in similar procedures in the future (e. Although some clinical acute pain stimuli clearly call for pharmacologi- cal intervention due to their severity (surgery), for other clinical sources of 245 246 BRUEHL AND CHUNG acute pain, such as injections and painful diagnostic procedures, exclusive reliance on pharmacological interventions may not be considered neces- sary or desirable given the brief duration of the pain, risk of side effects, or need for patients’ conscious awareness (e. Vari- ous psychologically based pain management interventions have been de- scribed for use in common clinical situations that result in acute pain (e. Although not intended to be an exhaus- tive review of the literature, this chapter describes a number of the tech- niques available and will overview evidence for their efficacy based on con- trolled clinical trials. Studies examining use of these interventions in comparison to or in conjunction with pharmacological analgesia will be summarized. Finally, issues involved in the practical use of such interven- tions in the clinical setting will be addressed. TYPES OF INTERVENTIONS Substantial research following the gate control theory of pain described by Melzack and Wall (1965) has confirmed the presence of descending neuro- physiological pathways through which psychological states can either ex- acerbate or inhibit afferent nociceptive input and the experience of pain. Al- though extreme emotional distress may be associated with stress-induced analgesia (Millan, 1986), at less extreme levels, greater emotional distress is generally associated with increased acute pain intensity (Graffenreid, Adler, Abt, Nuesch, & Spiegel, 1978; Litt, 1996; Sternbach, 1974; Zelman, Howland, Nichols, & Cleeland, 1991). Psychological strategies for managing acute pain therefore often intervene at the cognitive and physiological level to reduce distress and arousal that may lead to heightened experience of acute pain (Bruehl, Carlson, & McCubbin, 1993). In addition, the simple fact that a specific pain management technique has been provided is likely to in- crease patients’ perceived sense of control, which also appears to be an im- portant factor in reducing negative responses to painful stimuli (Litt, 1988; Weisenberg, 1987). Available psychological techniques for management of acute pain can be broadly categorized into information provision, relax- ation and related techniques, and cognitive strategies (e. Although some interventions, such as information provision, are primarily preemptive and designed to minimize pain by preparing the patient for what will be experienced, others such as relaxation techniques may be useful both preemptively and for reducing acute pain as the patient is experiencing it. Common psychological pain management techniques are summarized in Table 9. Relaxation related Breathing relaxation Simplest relaxation technique to implement. Progressive muscle relaxation Effective but may require re- peated training/practice ses- sions. Imagery Can use scripted, patient- developed, or memory-based relaxing imagery. Hypnosis Combines elements of relax- ation and imagery + sugges- tions of analgesia or sensory transformation. Distraction Includes visual or auditory stimuli, or mental and behav- ioral tasks that divert atten- tion away from pain. Sensory focus Encourages focus on the sensa- tions of the procedure being experienced. Prevents activa- tion of emotional schema that may increase pain sensation. Information Provision Two common information provision strategies target the sensations (e. Both strategies are based on a presump- tion that providing accurate information in advance regarding the sensa- tions and procedures that will be experienced will prevent development of inaccurate and fearful expectations that would otherwise elicit excessive anxiety and lead to increased pain sensations (Ludwick-Rosenthal & Neu- feld, 1988). For 248 BRUEHL AND CHUNG example, videotaped information provision interventions may portray the process of a real patient undergoing and coping well with the medical pro- cedure of interest (Doering et al. Scripted in-person presentations may also be used to describe the proce- dures and sensations the patient will be undergoing (Reading, 1982). To be effective, information provision interventions must be specific to the partic- ular clinical procedure that the patient will be undergoing. Relaxation and Related Techniques A variety of relaxation-related techniques are available that may have a positive impact on the pain experience.

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Yrjonen T (1992) Prognosis in Perthes’ disease after noncontain- orthosis for the treatment of Legg-Perthes disease order viagra vigour 800 mg mastercard. Müller was the first to describe this condition cheap viagra vigour 800mg amex, in 1888 buy 800mg viagra vigour, in his pa- per entitled »On abnormal curvatures of the femoral neck during growth« order 800 mg viagra vigour. Fat children and sporting children are particularly at risk of suffering a Occurrence slipped capital femoral epiphysis... An increase in the incidence of slipped capital ing ability [3, 28] femoral epiphysis has also been reported in the spring and – According to duration of symptoms summer months from April to August, while a more Acute Duration of symptoms <2 weeks recent study has observed a concentration of cases in the Fall. Its occurrence is also related to race: Slipped Chronic Duration of symptoms >2 weeks capital femoral epiphysis occurs more frequently in the Acute on Duration of symptoms >2 weeks, but with sudden black population than in whites [2, 31]. Our own study chronic deterioration of symptoms, inability to walk ( Chapter 1. Classification Slipped capital femoral epiphysis can be classified accord- those who are very keen on sports, the perichondrial ring ing to the duration of symptoms). The hormonal tion [3, 30] makes a distinction based on walking ability weakening of the epiphyseal plate is a physiological condi- (⊡ Table 3. Overweight, however, plays a major role in the etiology Etiology of slipped capital femoral epiphysis. In a recent study pa- Experimental investigations with animals have shown tients with this disease had significantly higher body mass that the mechanical strength of the epiphyseal plates is index than the control group. Testosterones promote growth, while cents with slipped capital femoral epiphysis and found estrogens tend to accelerate the maturation process. Tes- that these were normal in all cases, but that over half tosterones and estrogens occur in boys and girls at the of the children with this condition were clearly over- same time, but in differing concentrations. If the Because of its anatomical situation, the proximal hormone status is disrupted, however, a slipped capital femoral epiphyseal plate is subjected to very high shear femoral epiphysis can also occur in children of normal forces. This particularly applies in cases of hypothyroid- by the perichondrial ring of fibrous ligaments. This zone ism, growth hormone deficiency, panhypopituitarism and is thicker in small children than in adolescents during hypogonadism. If this zone is chronically hypopituitarism, causing the pubertal growth spurt to overloaded, as is often the case with obese adolescents or take place at an abnormally late stage, hence the possibil- 217 3 3. Adolescents with adiposogenital dystro- ence is also reflected by the fact, that in central Europe the phy (Fröhlich syndrome) are at particular risk. If bone age is considered, Pathophysiology there is a relatively short period of 4 years during which The slippage process is usually described as follows: The slipped capital femoral epiphysis can occur. A recent study found that 90% of cases occurred femoral neck rather than the head that actually slips. The in the accelerating phase of the pubertal growth spurt femoral head remains centered in the acetabulum, while ( Chapter 2. Two-thirds occur even the femur slips in a lateral and ventral direction. A recent study than a pure translation, this movement involves rotation on a population of very young patients (below age 10, n= about an eccentric axis. Finally, genetic components may in a medial and ventral direction, or of the femoral head also play a role, as has been demonstrated in a recent in a lateral and dorsal direction [46, 49]. Up to a certain extent, the slippage of the femoral head in a medial dor- sal direction is a physiological process. In children with coxa valga or an anteverted hip, this process takes place during growth and leads to physiological derotation. As well as weight, sporting activity also places a particular stress on the hip. A comparative investigation with two groups of adolescents showed that a tilt deformity oc- curred much more frequently in adolescents who actively participated in sports than in those who were less active a (⊡ Fig. Diagnosis A slipped capital femoral epiphysis is usually diagnosed on the basis of the pain reported by the patient. The pain is often stated to be in the thigh, or even in the knee, rather than the hip. The hip must therefore always be examined in ado- b lescents who complain of pain in the knee or thigh area.

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It is generally believed that undue pressure on the hip order viagra vigour 800 mg on line, combined with a lax hip joint capsule (i discount 800mg viagra vigour with amex. The unequal knee heights and asymmetricskin folds inthe uterine and abdominal musculature order viagra vigour 800mg with mastercard, and large thigh buy viagra vigour 800 mg with mastercard, seen in developmental displacement of the hip. The hip is initially examined with the baby supine and the hips flexed to 90 degrees, and with gentle but firm downward pressure on the femurs to fix the potentially moveable pelvis to the examination table. The fingers are positioned to provide for downward pressure on the femurs and to allow for direct vision of the thighs when abduction and adduction movements are attempted. Asymmetry of the thigh creases is readily appreciated in this position, as are differences in the height of the knees (Figure 3. The thighs are then gently and slowly parted (abducted with the middle or ring fingers palpating the greater trochanters). In unstable but “reducible” hips a discernible “clunk” will often be discerned in the neonate but commonly may recede to a “click” over the ensuing few months and then eventually disappear. The later discernible “click” obtained in near full abduction is usually a sign that the acetabular labrum has not firmly attached and stabilized, but is a sign of improved stability. If a true dislocation is evident, abduction will be clearly limited, as the head will not enter into the 25 Developmental displacement of the hip acetabular confines with attempts at reduction. A positive Barlow sign is actually a provocative dislocation or subluxation test, and is elicited using the thumb and fingers to laterally move the femoral head out of the acetabular confines by lateral pressure of the inner aspect of the thigh (Figure 3. Perhaps the most valuable sign of hip instability (subluxation or dislocation) is the “pistoning” or “telescoping” sign. It is generally elicited by stabilizing the pelvis with one hand firmly against the anterior iliac spine, grasping the femur in the other hand, then “pumping” downward and upward in a vertical direction with the hip flexed to 90 degrees (Figure 3. The femur will glide up and down within the soft tissue envelope of the thigh and independent of the stable pelvis. As the femur glides within the soft tissue envelope, the pelvis remains fixed with each up and down thrust. It is imperative that the novice clinically examines as many hips as possible Figure 3. As the child approaches six months of age, dislocation may lead to an adduction contracture, and reduction of the hip becomes much more difficult with the disappearance of the Ortolani sign. Diagnosis in the ambulatory child should be much easier with shortening, limp, and telescoping more obvious. The natural history or evolution of a displaced hip in infancy has been the topic of considerable investigation and commentary. Most people agree that there is a tremendous tendency for the hip to stabilize spontaneously, with a likelihood of 85–90 percent of all hips achieving stabilization by 9–10 months of age. Unfortunately, we are presently unable to predict which hips will stabilize, and we are left with 10–15 percent who will remain with varying degrees of hip malpositioning, including even frank dislocation. The future of Common orthopedic conditions from birth to walking 26 hip joint function appears directly related to the early recognition of this problem. Careful hip examination should take place from birth to one year of age at regular intervals. The role of radiographic examination or the use of ultrasound is less clearly defined. The femoral head does not normally ossify its secondary ossification center until roughly three to six months of age, and that ossification of the center is commonly delayed even further in developmental displacement of the hip. While there is nothing wrong with performing an imaging examination at three to six months of age, particularly in high risk infants, it should never replace a careful hip examination. Bilaterally involved hips pose the greater hazard, and make the individual hip examination even more important, as “widening” of the perineum seen in bilaterality is very difficult to discern in infants and young children. Radiographic examination of the hips in very young children is fraught with potential misinterpretation errors. To be at all meaningful, anteroposterior examination must be done with the hips and knees maximally extended, and with the patella directed vertically (Figure 3. Abduction views of the hips tend to induce femoral head relocation, and external rotation positioning promotes lateralization of an already anteverted femoral head and neck. If one couples that information with the fact that the femoral head is for all parts a chondroepiphysis, with an occasional degree Figure 3. The positioning of the child for standard anteroposterior radiographs of the hip.

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