By S. Cruz. Mount Mercy College.
Antero-posterior projections in the prone position purchase 5mg dulcolax amex, with 45° caudal angulation of the central ray to show the sigmoid colon cheap dulcolax 5mg online, and lateral decubitus projections order 5mg dulcolax otc, may be required for a complete study buy dulcolax 5 mg lowest price, but are not routinely taken. In these cases, anti- spasmodic agents may be given prior to examination to relax the bowel after which air at a pressure not exceeding 80mmHg is insufﬂated over 3 minutes. The child should be rested for 3 minutes before repeating this procedure. At no time should the pressure exceed 120mmHg10 and a maximum of three attempts should be made. In a successful examination, ﬂuoroscopy will demonstrate air bubbling through the site of the intussusception. Surgical reduction may be required if the image-guided reduction attempt fails, and surgical staff should be made aware of the procedure in case of a surgical emergency. Contraindica- tions to the air enema are suspected perforation or peritonitis. Renal tract examinations Intravenous urography Ultrasound is the initial imaging examination of choice for renal tract pathology in the child and intravenous urography (IVU) is required only when less inva- sive procedures have failed to provide adequate diagnostic information. Prior to administration of a contrast agent, the child should be weighed and the dose calculated in accordance with the manufacturer’s instructions on 90 Paediatric Radiography volume and concentration in terms of iodine content per kilogram of body weight. A topical local anaesthetic should be applied to several potential injection sites at least 1 hour prior to radiographic examination to facilitate intravenous puncture or, alternatively, the contrast agent may be administered through an existing intravenous line where one is already in situ. It is standard practice to starve the patient for 4 hours prior to the adminis- tration of a contrast agent in order to ensure that the stomach is empty. However, it is important that patients, particularly children, remain well hydrated and clear ﬂuids should not be restricted. Flexibility in examination appointment times, particularly for infants and young children, will be necessary so that the examination can be timed for when the stomach is likely to be empty (i. Following contrast agent injection, infants may be bottle-fed to help pacify them. The ﬂuid-ﬁlled stomach will effectively form a radiographic ‘window’ facilitating the visualisation of the renal area. Each IVU examination should be tailored to the individual patient and directed to answer a speciﬁc clinical question13 thereby ensuring that the number of radiographic images taken is kept to a minimum. Ideally, the renal tract should be visualised free from overlying bowel gas and faeces, and the use of ureteric compression and oblique projections may be required to achieve this. Oral car- bonated drinks can be used in older children to distend the stomach and provide a gaseous ‘window’ through which the kidneys may be visualised; the antero- posterior projection with the patient supine demonstrating the left kidney while a right posterior oblique will demonstrate the right kidney. Alternatively, the kidneys may be visualised by an antero-posterior projection with the patient supine and 35° caudal angulation centred to the xiphisternum. Micturating cystourethrography Micturating cystourethrography (MCU) is the deﬁnitive method of assessing the lower urinary tract13. It is particularly valuable for the assessment of male urethral pathology (e. This examination requires a small catheter to be inserted into the bladder via the urethra and although this procedure is performed under strict asepsis, it is still associated with a ﬁnite risk of urinary tract infection. As a result, prophy- lactic antibiotic cover may be prescribed prior to the examination or post- examination if warranted by the diagnostic outcome (e. Micturating cystourethrography is contraindicated in cases of proven current infection or where a documented infection has occurred during the 4- week period prior to the examination. It is important that a clear and honest explanation of the procedure is given to the child and their guardian prior to entering the imaging room and written informed consent must be obtained. In departments where micturating cys- The abdomen 91 tourethrography is commonly performed, a special doll with interchangeable genitalia may be used to demonstrate the catheterisation technique in order to reduce anxiety and maximise co-operation. Micturating cystourethrography will invariably involve soiling the child’s clothing and therefore the child should be changed into a paediatric hospital gown or, in the case of very young children, hospital-owned vest and top. Alternatively the patient may prefer to wear their own, familiar clothes and should be instructed to bring a change of suitable cloth- ing with them.
Careful curettage is required in such cases (see the rotated foot is difficult for the parents and child to chapter 4 discount 5mg dulcolax amex. The recurrence rate of accept psychologically discount dulcolax 5mg without prescription, the functional advantages these tumors can be reduced from over 50% to less than over amputation are so great that the esthetic disadvan- 10% with effective curettage [15 cheap dulcolax 5mg visa, 26] cheap dulcolax 5 mg on-line. If the fibular head tages usually become well tolerated with time [17,18, 23, needs to be resected because of a tumor, a corresponding 46] ( Chapter 4. A rotationplasty is also a suitable replacement must be constructed in order to provide an »salvage operation« in cases of infection or the failure of anchoring point for the lateral collateral ligament and the prostheses or allografts. AP MRI and lateral x-ray (a) of the left knee of a 15- year old boy with a giant cell tumor in the area of the fibular head. The patient’s knee is very stable for the complete distal femur or proximal tibia is feasible (⊡ Fig. The advantage of the allograft over a joint prosthesis is the possibility of preserving the part of the joint opposite the tumor. At the proximal tibia this provides a better anchoring option, compared to a b prosthesis, for the patellar tendon (and thus the complete extensor apparatus). Although considerable experience – up to 36 years – has been accumulated with the use of such large allografts, certain disadvantages should be Reconstruction options mentioned: for example, joint function is not usually very The treatment of malignant tumors of the distal femur good, the mechanical strength is inferior to that of metal or proximal tibia is usually associated with the loss of all implants, and the complication rate is very high (40% or part of the joint surface. Only those tumors located fractures, 15% infections) [9, 12, 19, 30, 36]. The recon- become a standard method of treating malignant tumors structive measures in this case are limited to the anchor- in the knee area. These are modular prosthesis with resec- ing of the lateral ligamentous apparatus of the knee. The fem- many cases, however, the peroneal nerve also needs to oral and tibial sections are firmly linked by a hinge joint. The most widely-used surface must be removed as well then reconstruction will prostheses in Europe are the implant developed by Kotz be required ( Chapter 4. We In our experience, the use of allografts in the knee routinely use such prostheses particularly for tumors of area has not proved effective particularly in those cases the distal femur (⊡ Fig. Since the anchoring point in which only a part of the joint surface of the femur or of the extensor apparatus can be preserved, the functional tibia has to be removed. The short- and medi- as the anchorage for the patellar tendon is inadequate on um-term results of treatment with tumor prostheses are the tumor prosthesis. With an allograft however, the fixed very good, although long-term results, for example tendon can integrate with the allograft, which is not pos- over a period of 50 years and more after the implantation sible with a metal implant (⊡ Fig. The soft tissue covering occasionally represents a We have not had much experience with the combination critical problem, hence the frequent use of gastrocne- of a homogenous osteocartilaginous graft (allograft) 3 b ⊡ Fig. AP and lateral x-rays (a top row) and frontal and sagittal MRI scans (a bottom row) of the right knee of a 17-year old girl with a chondrosarcoma of the distal femur in the area of the medial femoral condyle. AP and lateral x-rays (a) of a 14-year old girl with an osteosarcoma in the metaphyseal/diaphyseal area of the proximal tibia. Such combinations are usual and is occasionally required if the use of a prosthesis is not useful at the proximal femur, but less so in the knee possible. The literature only offers a few reports on such Another alternative in children under 10 years of age combinations. There are only isolated reports on is the extendable prosthesis [10, 11, 13]. Some centers the procedure involving removal of the tumor with the now have over 20 years’ experience with such prostheses. An arthrodesis triggered by forced knee flexion, thereby minimizing the a b c ⊡ Fig. Bottom row (d, e): Situation 1 year after resection and insertion of a tumor prosthesis with 2 rotating axes (»rotating hinge«) and partial preservation of the tibial tuberosity and thus the d e extensor apparatus 360 3.
Con- siderable research has examined children’s concepts of general illness from a developmental perspective (Bibace & Walsh buy dulcolax 5 mg mastercard, 1980; Burbach & Peter- son generic 5 mg dulcolax with mastercard, 1986) order dulcolax 5 mg free shipping, with most data suggesting that children’s concepts of illness evolve in a systematic purchase dulcolax 5 mg online, age-related sequence, consistent with Piagetian the- ory of cognitive development. Far less research has examined the develop- mental course of children’s specific understanding of pain. Harbeck and Pe- terson (1992) found, among a sample of children and youth aged 3 to 23 years, that older children and youth had more complex and precise under- standings of pain than younger children. For example, children in the preoperational stage of development were unlikely to be able to offer an ex- planation for the value of pain, whereas children in the formal operations stage were able to acknowledge that pain often carries a preventative or di- agnostic value (Harbeck & Peterson, 1992). Ability to understand the cause and value of pain is likely related to pain perception, although no research has explored the links between children’s understanding of pain and subse- quent pain responses. Research has also confirmed the presence of age- related differences in children’s predictions of pain intensity, with younger children making less accurate predictions than older children (von Baeyer, Carlson, & Webb, 1997). Children’s coping strategies for dealing with pain are an area that has re- ceived considerable research attention (Bennett-Branson & Craig, 1993; Reid, Gilbert, & McGrath, 1998). Reid and colleagues (1998) detailed the devel- opment of a measure of pain coping in children that assessed coping in three broad areas: approach (e. Use of this measure among a sample of children aged 8 to 18 years revealed that adolescents (13–18 years) reported higher levels of emotion-focused avoidance than children aged 8 to 12 years (Reid et al. The authors attributed this finding to increased frequency of pain among adolescents for which they may experience difficulties managing and consequently re- sort to more emotion-focused avoidant approaches. Other research has examined children’s coping with postoperative pain (Bennett-Branson & Craig, 1993). Results of this research showed that older children (aged 10 to 16 years) spontaneously reported a higher frequency of cognitive coping 5. PAIN OVER THE LIFE SPAN 121 strategies for dealing with postoperative pain when compared to younger children (aged 7 to 9 years). The family is a common social factor that is related to children’s pain experiences (McGrath, 1994). Studies of the aggregation of pain com- plaints in families have highlighted the important context of the family in childhood pain (Goodman, McGrath, & Forward, 1997). For example, stud- ies have shown that children with recurrent abdominal pain are more likely to have parents who report similar pain problems (Apley, 1975; Apley & Naish, 1958; Zuckerman, Stevenson, & Bailey, 1987), and that per- sons with recurrent pain often come from families with a positive family history for pain (Ehde, Holm, & Metzger, 1991; Turkat, Kuczmierczyk, & Adams, 1984). Parental modeling and reinforcement of pain are often hypothe- sized to be important mechanisms that could contribute to transmission of pain within families (Craig, 1986). Recent research has shown that pa- rental behavior can have a strong direct effect on children’s pain experi- ences (Chambers, Craig, & Bennett, 2002); however, to date, no research has examined family influences on children’s pain experiences as a func- tion of age of the child. It seems probable that parental influences might be most salient among younger children. Similar to adult populations, emotional factors, such as anxiety, fear, frustration, and anger, are also related to children’s pain expression in im- portant ways (Craig, 1989; McGrath, 1994). For example, in a study of chil- dren aged 7 to 17 years undergoing surgery, anticipatory anxiety emerged as a significant predictor of children’s postoperative pain experiences (Pa- lermo & Drotar, 1996). Further, research has shown age-related effects in children’s decisions to control or express emotions (Zeman & Garber, 1996). Results of this research, which compared children aged 6 to 10 years, showed that younger children were more willing to express emotions such as anger and sadness than older children (Zeman & Garber, 1996). It is likely that age-related differences in children’s emotional displays are asso- ciated with developmental changes in children’s pain expression. In summary, a variety of psychosocial factors can impact on children’s pain experiences. The majority of research has been conducted in the early to middle childhood periods. Additional research focusing on age-related differences in psychosocial factors that influence pain among infants and adolescents is needed. Regardless, existing data appear to support the no- tion that developmental differences in psychosocial factors likely contrib- ute to children’s pain experiences and expression.
Med Sci Sports Exerc of the World Heart Federation buy 5 mg dulcolax visa, the International Federation of 27:641–647 buy dulcolax 5 mg on line, 1995 buy dulcolax 5mg mastercard. Sports Medicine order 5 mg dulcolax mastercard, 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). COLD MILIARIA CHILBLAIN Miliaria rubra, or prickly heat, occurs in hot, humid Chilblain or pernio is the mildest form of cold injury summer environments. SOLAR URTICARIA Topical corticosteroids or a short burst of oral corti- Solar urticaria is an uncommon cause of urticaria in costeroids may be utilized to minimize the painful, athletes (Kantor and Bergfeld, 1988). FURUNCULOSIS Frostnip can be reversed with immediate self-rewarm- Erythematous, nodular abscesses found in the hairy ing of the exposed area. HERPES GLADIATORUM The sharply, demarcated reddish-brown plaques are Herpes gladiatorum or rugbeiorum refers to a herpes similar in appearance to tinea cruris (Bergfeld, 1984). MOLLUSCUM CONTAGIOSUM The majority of cases respond promptly to topical Characterized by small umbilicated, flesh-colored, antifungal creams, such as miconazole, clotrimazole, and dome-shaped papules. CHAPTER 26 DERMATOLOGY 155 TINEA CORPORIS In extensive disease, oral ketoconazole 200 mg daily Annular lesion having a sharply demarcated, red- for 5 days or 400 mg once a month has been shown dened border with central clearing. ONYCHOMYCOSIS Recent studies reveal oral fluconazole, 200 mg, taken Onychomycosis is a common toenail fungal infection once weekly for 4 weeks had negative cultures after known as tinea unguium and can be attributed to either 7 days in 60% of the wrestlers (Adams, 2002b). MISCELLANEOUS Oral antifungal agents may be required in recalcitrant cases, if the hair roots are involved. CONTACT DERMATITIS Tinea cruris must also be differentiated from candidia intertrigo (scrotal involvement and satellite lesions), Primary irritant dermatitis is a nonallergic reaction that erythrasma (brown and scaly, fluoresces coral red), leads to symptoms within minutes of the exposure psoriasis (silvery scale, pitted nails, and scalp (Bergfeld, 1984).