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A defini- tive diagnosis can normally be made following clinical examination and plain film radiography is NOT indicated purchase malegra dxt 130 mg line erectile dysfunction treatment natural. Note the typical ‘wine bottle’-shaped airway on antero-posterior (AP) projection buy malegra dxt 130 mg online erectile dysfunction after 80. Epiglottitis Epiglottitis is an inflammatory condition of sudden onset and progression that presents in children between the ages of 2 and 7 years. The child will typically sit forward, open mouthed and drooling and, as this condition is a paediatric emergency, should be transferred to a paediatric intensive care unit where inves- tigative laryngoscopy will be undertaken to confirm the clinical diagnosis. The lower/intra-thoracic airway Asthma Asthma is an umbrella term for a variety of paediatric chest conditions that result in a persistent or episodic wheeze, possibly associated with a cough. Symptoms typically present in children over the age of 3 years and are more common in the winter months, due to an increase in viruses, and in autumn/spring as a conse- quence of pollen. A child known to suffer from asthma does not require radiographic examina- tion with each episode. However, a chest radiograph is indicated if other respi- ratory conditions are suspected (e. Radiographically, patients with asthma may have a normal chest radiograph therefore supporting the view that asthma is a clinical diagnosis. Tracheo-oesophageal fistula A tracheo-oesophageal fistula is a variation of oesophageal atresia that presents during the neonatal period (see Chapter 6). Radiographic identification of the site of atresia can be made following the insertion of a radio-opaque feeding tube into the oesophagus. This tube will ‘curl’ at the site of the atresia and a single antero-posterior projection of the upper abdomen, chest and pharyngeal region should be undertaken. Air identified within the stomach on this projection sug- gests the presence of a distal fistula. Presentation of oesophageal atresia outside the neonatal period is unusual but may occur with an undiagnosed H-type fistula where the patient presents with repeated chest infections. In these cir- cumstances, a fluoroscopic contrast examination will confirm the diagnosis. Bronchiolitis Bronchiolitis is the commonest lower respiratory tract infection of infancy with the peak age at presentation being 3 months2,6. A plain film radiograph of the chest will display marked hyperinflation of the lungs and possible areas of peribronchial thicken- ing and consolidation. Radiographic appearances are dependent upon the aetiology with viral infections causing air trapping, seen as hyperinflation on the chest radiograph (Fig. Bronchiectasis Bronchiectasis is defined as the chronic, irreversible dilation and distortion of the bronchi caused by inflammatory destruction of the muscular and elastic com- 8 ponents of the bronchial walls. It may be congenital or acquired but usually results from a longstanding localised bronchial infection. Plain film chest radi- ography is generally insensitive and seldom demonstrates the anatomic distri- bution of the disease unless the condition is severe when dilated bronchioles will appear as parallel densities (tram lines). Atelectasis may also be seen in severe cases and high-resolution computerised tomography (CT) may be considered to assess the extent and severity of the disease (Fig. Pulmonary tuberculosis Tuberculosis is an infection caused by Mycobacterium tuberculosis and, although it is relatively uncommon, incidences of tuberculosis are increasing throughout the world. In the UK, tuberculosis is associated particularly with the immigrant population (especially from Asia, Africa and Latin America), the homeless, the elderly and the immunosuppressed (e. In children, tuber- culosis infection is typically due to prolonged and close contact with an indi- vidual having active and untreated disease. The radiographic appearances of pulmonary tuberculosis are varied and dependent upon the age of the child. Progressive pulmonary tuberculosis most commonly occurs during infancy as a result of the primary infection not being contained, and subsequently progresses to bronchopneumonia, lobar pneumo- nia (usually middle or lower lobe) and cavitation. In contrast, primary pul- monary tuberculosis in older infants and children is usually an asymptomatic illness with minimal abnormalities demonstrated on the chest radiograph, while adolescent infection will follow more closely the typical adult appearances with upper lobe opacification and possible cavitation. Widespread haematogenous dissemination of tuberculosis following primary infection is uncommon and is 9 normally restricted to children under 2 years of age (Fig.

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The central network projecting to the central cell represents Livingston’s (1943) conceptual model of reverberatory circuits underlying pathological pain states malegra dxt 130mg on-line causes juvenile erectile dysfunction. The output projects to spinal cord neurons effective 130 mg malegra dxt erectile dysfunction scrotum pump, which are conceived by Noordenbos (1959) to comprise a multisynaptic affer- ent system. The large (L) and small (S) fibers project to the substantia gelatinosa (SG) and first central transmission (T) cells. The central control trigger is represented by a line running from the large fiber sys- tem to central control mechanisms, which in turn project back to the gate con- trol system. THE GATE CONTROL THEORY OF PAIN In 1965, Melzack and Wall proposed the gate control theory of pain. The gate control theory of pain (Melzack & Wall, 1965) proposes that the transmission of nerve impulses from afferent fibers to spinal cord transmis- sion (T) cells is modulated by a gating mechanism in the spinal dorsal horn. This gating mechanism is influenced by the relative amount of activity in large- and small-diameter fibers, so that large fibers tend to inhibit trans- mission (close the gate) while small fibers tend to facilitate transmission (open the gate). In addition, the spinal gating mechanism is influenced by nerve impulses that descend from the brain. When the output of the spinal T cells exceeds a critical level, it activates the action system—those neural areas that underlie the complex, sequential patterns of behavior and expe- rience characteristic of pain. Publication of the gate control theory received an astonishing reception. The theory generated vigorous (sometimes vicious) debate as well as a great deal of research to disprove or support the theory. The search for specific pain fibers and spinal cells by our opponents now became almost frantic. It was not until the mid-1970s that the gate control theory was pre- sented in almost every major textbook in the biological and medical sci- ences. At the same time, there was an explosion in research on the physiol- ogy and pharmacology of the dorsal horns and the descending control systems. The theory’s emphasis on the modulation of inputs in the spinal dorsal horns and the dynamic role of the brain in pain processes had a clinical as well as a scientific impact. Psychological factors that were previously dis- missed as “reactions to pain” became seen to be an integral part of pain processing and new avenues for pain control by psychological therapies were opened. Similarly, cutting nerves and pathways was gradually re- placed by a host of methods to modulate the input. Physical therapists and other health-care professionals who use a multitude of modulation tech- niques were brought into the picture, and TENS became an important mo- dality for the treatment of chronic and acute pain. The current status of pain research and therapy has recently been evaluated and indicates that, despite the addition of a massive amount of detail, the conceptual compo- nents of the theory remain basically intact up to the present. Melzack and Casey (1968) made a start by proposing that specialized sys- tems in the brain are involved in the sensory-discriminative, motivational- affective, and cognitive-evaluative dimensions of subjective pain experience (Fig. These names for the dimensions of subjective experience seemed strange when they were coined, but they are now used so frequently and seem so “logical” that they have become part of our language. The gate theory also postulated that the brain exerted a tonic inhibitory effect on pain. An experiment by Melzack, Stotler, and Livingston (1958) re- vealed the midbrain’s tonic descending inhibitory control and led directly to Reynolds’s (1969) discovery that electrical stimulation of the periaque- ductal gray produces analgesia. This study was followed by Liebeskind’s re- search (Liebeskind & Paul, 1977) on pharmacological substances such as endorphins that contribute to the descending inhibition. The observation that “pain takes away pain,” in which Melzack (1975b) postulated that de- scending inhibition tends to be activated by intense inputs, led to a series of studies on intense TENS stimulation. Later, a series of definitive studies on “diffuse noxious inhibitory controls” (DNIC) firmly established the power of descending inhibitory controls (Le Bars, Dickenson, & Besson, 1983; Fields & Basbaum, 1999). Conceptual model of the sensory, motivational, and central control de- terminants of pain. The output of the T (transmission) cells of the gate control system projects to the sensory-discriminative system and the motivational- affective system. The central control trigger is represented by a line running from the large fiber system to central control processes; these, in turn, project back to the gate control system, and to the sensory-discriminative and motiva- tional-affective systems.

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Other causes of UAO generic malegra dxt 130mg overnight delivery erectile dysfunction and diabetes leaflet, such as airway in place forces the neck out of a neutral position edema from anaphylaxis buy malegra dxt 130mg with amex gluten causes erectile dysfunction, inhalation burn injuries, or (Haight and Shiple, 2001; Gastel et al, 1998). If the an expanding neck or retropharyngeal hematoma athlete is not wearing a helmet, a rigid cervical collar from neck trauma should be considered, with early should be applied with in-line immobilization of the intubation a priority. Although airway obstruction may fallen athlete include whether or not the injury was not be immediate, it can rapidly progress to this stage witnessed/unwitnessed and/or traumatic/atraumatic. Finally, the environ- rupture of a bleb) or traumatic, with spontaneous mental conditions must be considered as both a pneumothoraces occurring more often in sports that potential causative and/or exacerbating factor in the involve changes in intrathoracic pressure (i. Symptoms may include unilateral chest categorize them as being of either an immediate or pain, dyspnea, and cough. Immediate treatment is potential life threatening/disabling nature and treat rarely needed unless the patient is severely dyspneic accordingly. Frequent reevaluation of the injured ath- or the pnuemothorax is open or under tension. OPEN PNEUMOTHORAX This is defined as a pneumothorax accompanied by an open wound to the chest (sucking chest wound). ANAPHYLAXIS Treatment consists of placing an occlusive dressing over the open wound and taping it down on three sides Anaphylactic reactions are acute systemic hypersensi- to create a one-way valve that allows air to exit with- tivity reactions that can be idiopathic, exercise- out reentering till a definitive thoracostomy tube can induced, or allergen-induced, and although rare, they be placed. In addition to the previ- typically rapid (within 5–30 min of exposure), and in ously listed symptoms, these athletes may have tra- its most severe form can progress to severe bron- cheal deviation away from the affected side with chospasm, airway edema, and fatal cardiovascular col- jugular venous distention and hypotension. CARDIAC ARREST The athlete must be rapidly transported to a medical facility as continued observation will be required. The most common cause of sudden cardiac death in young ath- Hemorrhage in the athlete may be the result of lacera- letes is congenital cardiovascular structural abnormali- tions, fractures, vascular disruptions, or visceral organ ties with hypertrophic cardiomyopathy leading the list, or muscle disruptions. It can manifest as either mas- followed by coronary artery anomalies and myocarditis sive external bleeding or insidious and occult internal (McCaffrey et al, 1991). Control of external bleeding should follow older athletes (age > 30–35) is atherosclerotic heart dis- the basic principles of hemostasis, which include ease causing acute ischemic events. Blind clamping of guidelines with attention to early cardiopulmonary bleeding vessels and tourniquet application (with the resuscitation (CPR) and defibrillation as indicated. An possible exception of a traumatic amputation) are not equally important task for the FP is to identify those recommended. Strong consideration toms, and what may at first appear to be an atraumatic 14 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE incident may actually have been caused by recent unno- even if the initial examination is completely normal, ticed or unwitnessed trauma (Blue and Pecci, 2002 ). Consideration should be the three most commonly used systems assess sever- given to starting crystalloid fluids, although there is ity based on the presence or absence of an LOC and/or some debate as to whether or not aggressive fluid posttraumatic amnesia, as well as the duration of post- resuscitation may actually be more detrimental to concussive symptoms (PCS). No athlete should return to play while any symp- toms are still present either at rest or with exertion. No athlete should return to play on the same day if POTENTIAL LIFE THREATENING/ the concussion involved an LOC (even if brief) or DISABLING INJURIES if postconcussive symptoms are still present 15–20 min after the injury. An athlete with a mild concussion (Grade 1) with no LOC and resolution of PCS within 15–20 min Head injuries in sports are quite common and often both at rest and with provocative exertional maneu- provoke anxiety and uncertainty. Fortunately, the vers may safely return to play that same day, pro- most common head injury in sports is a concussion vided this was the first concussion. Regardless of whether an athlete returns to play or loss of consciousness (LOC) (McAlindon, 2002; is disqualified from play for that day, frequent Harmon, 1999). The FP must learn not only how to reevaluation and serial examinations are absolutely recognize them (which is not always easy) and mandatory. Assessment temporoparietal region and is associated with a skull for potential spine injury should be done, and once on fracture 80% of the time. Athletes will often experi- the sidelines, a full neurologic examination performed, ence a brief LOC followed by a lucid interval which including a full sensory, motor, and cranial nerve may last up to several hours, and then progress to examination as well as cognitive functioning and rapid neurologic deterioration and eventually coma memory testing. Treatment is surgical and Obvious signs of skull fracture or intracerebral bleed- immediate transfer to a medical facility is required. It must be emphasized that the symptoms of a first head injury have resolved. CHAPTER 4 FIELD-SIDE EMERGENCIES 15 A controversial topic, it is a catastrophic injury that Although there are no definitive guidelines as to may occur because of a loss of cerebral autoregulation which athletes with neck injuries are safe to return to caused by the initial injury (Harmon, 1999; Crump, play, it is generally agreed on that only those players 2001; Graber, 2001). When the second injury occurs, with absolutely no neck pain or neurologic symptoms and it is often a very mild injury, cerebral edema rap- and with completely normal examinations may return idly develops with subsequent brainstem herniation to play safely, with repeated evaluation being within a matter of seconds to minutes.

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Depression is a better predictor of disability than pain intensity and duration [Rudy et al generic malegra dxt 130mg mastercard erectile dysfunction medication for diabetes. For example cheap 130mg malegra dxt amex how to treat erectile dysfunction australian doctor, fibromyalgia patients with depression compared to those without were significantly more likely to live alone, report functional disability, and describe maladaptive thoughts [Okifuji et al. A naturalistic follow-up study of patients with chronic pain who had substantial numbers of sick days found that a diagnosis of major depression predicted disability an average of 3. The presence of depression in whiplash patients reduced the insurance claim closure rate by 37% [Cote et al. This rate was unaffected even after the insurance system eliminated compensation for pain and suffering. Preoperative major depression in patients undergoing surgery for thoracic outlet syndrome increased the rate of self-reported disability by over 15 times [Axelrod et al. In patients with rheumatoid arthritis, depressive symptoms were significantly associated with negative health and functional out- comes as well as increased health services utilization [Katz and Yelin, 1993]. Depression consistently predicted level of functioning, pain severity, pain-related disability, less use of active coping, and more use of passive coping in patients in a university chronic pain inpatient unit [Fisher et al. Patients suffering from chronic pain syndromes including migraine, chronic abdominal pain, and orthopedic pain syndromes report increased rates of suicidal ideation, suicide attempts, and suicide completion [Fishbain, 1999; Fishbain et al. In one study of patients who attempted suicide, 52% suffered from a chronic somatic disease and 21% were taking analgesics on a daily basis for pain [Stenager et al. Patients with chronic pain completed suicide at 2–3 times the rate in the general population [Fishbain et al. Cancer patients with pain and depression, but not pain alone, were significantly more likely to request assistance in committing suicide as well as actively take steps to end their lives [Emanuel et al. Clark/Treisman 8 The determination whether negative affect represents a diagnosis of major depression as opposed to psychological distress varies widely. Principal- component analyses of the responses of patients with chronic pain on the BDI find three factors consistent with the core criteria of major depression: low mood, impaired self attitude, poor vital sense [Novy et al. In a study comparing separate measures of affective distress, self-reported depressive symptoms, and major depression in patients with chronic pain at a pain clinic, a diagnosis of major depression was deter- mined to be a less sensitive indicator and less important predictor of the chronic pain experience than self-reported depressive symptoms [Geisser et al. The presence of depressive symptoms, even without the categorical diagnosis of major depression, is an important comorbidity for patients with chronic pain [Bair et al. However, if treatment for depression is to be rationally designed and effective, the specific form of depression must be discovered. Treatment for a disease involves finding a cure for the pathology and restoring function to premorbid levels. The cure may repair the broken part, prevent the initial damage from occurring, or compensate for the affected phys- iology. The etiology of major depression is elusive and treatments are currently unable to permanently correct the underlying pathology, however many patients are completely free of depressive symptoms while in treatment with antidepres- sant medications. Major depression must be distinguished from an expected demoralization and sadness that can be ‘understood’ as an outcome of suffering with chronic pain. Because physicians are compassionate and empathize with their patients they may ‘understand’ the depressive feelings associated with major depression and fail to adequately utilize specific psychological and pharmaco- logical therapies. Life Stories (table 1) An important component of a person’s response to adversity is that person’s assumptions about the world. These assumptions are based on experiences and the meaning derived from them. A person who is misused by authority figures such as parents during childhood will have problems successfully interacting with authority figures in adulthood. More importantly, a person’s assumptions about the world will in part direct their experiences in the future. This means that a set of negative experiences occurring at a vulnerable time will be magnified by shaping future experiences. A cycle of negative experience leads to meaningful assump- tions that then direct behavior.

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It typically results from a fall on an outstretched hand while the 140 Paediatric Radiography (a) (b) Fig generic malegra dxt 130mg online erectile dysfunction treatment home remedies. Note the radiocapitellar line is drawn through the proximal radial shaft buy malegra dxt 130 mg visa doctor of erectile dysfunction. A subtle supracondylar fracture line may not be visible on the antero-posterior projection of the elbow. However, the lateral projection will gen- erally show anterior and posterior fat pad displacement and posterior movement of the humeral condyles relative to the humeral shaft when assessed using the anterior humeral line (Fig. Condyles Isolated lateral humeral condyle fractures account for up to 20% of all paediatric elbow injuries and frequently result from a fall on an outstretched hand (Fig. They are generally reported as Salter-Harris type III or type IV injuries involving the capitellum and are most commonly seen in children between the ages of 5 and 10 years. Identification of this injury is important as the frac- ture fragment can be pulled postero-inferiorly and result in valgus deformity, ulnar nerve palsy and premature physeal fusion unless adequate reduction is 6 achieved. In contrast, isolated medial humeral condyle fractures are rare and usually present as a Salter-Harris type IV injury. Note that although a fracture line is difficult to identify on the antero-posterior projection (a), raised fat pads (dashed lines) and posteriorly displaced humeral condyles on the lateral projection (b) indicate the presence of a supracondylar fracture. The mechanism of injury is commonly a fall on an outstretched hand resulting in severe valgus elbow strain. The avulsed medial epicondyle will generally move inferiorly and may become trapped within the elbow joint space where it can be confused with the trochlear ossification centre. As the epicondyle may lie outside the joint capsule, this injury will not necessarily have an associated effu- sion and elevated fat pads. The most useful evaluation tool to ensure that this injury is not missed is therefore the CRITOL mnemonic (Fig. Proximal radius Although common in adults, radial head injuries are rare in children as ossification of the radial head is not complete until approximately 10 years of age. Instead, Salter-Harris type II fractures of the radial neck tend to occur and these injuries are best demonstrated on the lateral elbow projection (Fig. Proximal ulna Fractures of the proximal ulna tend to involve the olecranon process (Fig. Olecranon fractures occur following a fall on an outstretched hand or as a result of a direct blow to the elbow and are frequently associated with proximal radius fractures (Fig. Separation of the fracture fragments can occur on contraction of the triceps muscle if the fracture is distal to the site of the triceps muscle insertion (Fig. Elbow dislocations Although true joint dislocations are rare in children, a dislocation at the elbow may occur and typically results in posterior movement of the radius and ulna relative to the humerus7 (Fig. The mechanism of injury is usually a fall on an outstretched hand and an associated fracture of the coronoid process, as a result of impaction against the trochlea, may be seen. Occasionally, following complex trauma, more unusual dislocations occur and radiographers should be wary of the rare true medial or lateral dislocation which can appear normal on the lateral elbow projection. Separation of the entire distal humeral epiphysis in very young children may be confused with a joint dislocation. However, main- tenance of the normal radiocapitellar relationship differentiates this injury from a true dislocation. Note the variation in the position and appearance of the avulsed fragment. It is not uncommon for fractures of both the radius and ulna to occur at the same level following direct trauma (Fig. Alternatively, a fracture of one bone may be associated with a plastic bowing Skeletal trauma 145 Fig. Monteggia-type lesions, consisting of a mid-shaft ulna fracture with associated anterior radial head dislocation, are seen in children in many forms2 and it is essential that forearm radiographs include both wrist and elbow joints to allow the accurate assessment of bony alignment and reveal any associated joint injuries. The wrist The most common childhood skeletal injury is the distal radius fracture.

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