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Malignant tumors of the proximal femur are fairly 267–70 rare – usually involving osteosarcomas atorlip-10 10 mg with amex, and occasion- 268 3 best 10mg atorlip-10. The femoral shaft is primarily affected by osteoid os- teomas cheap atorlip-10 10 mg mastercard, enchondromas and osteochondromas that grow Diagnosis from the metaphysis into the diaphysis (⊡ Table 3 buy atorlip-10 10mg amex. Of Tumors in the vicinity of the pelvis and proximal femur the malignant tumors in adolescents cheap 10 mg atorlip-10 with mastercard, we have observed are surrounded by large soft tissue masses. Since these several osteosarcomas, but surprisingly few Ewing’s sar- only become palpable when they reach a very respectable 3 comas exclusively in the femoral shaft, even though this size they are extremely difficult to diagnose and often tumor forms in the medullary space. If unclear, non-load-related pain occurs in the area medullary space, in which case it becomes a metaphyseal/ of the pelvis or thigh an x-ray should always be re- diaphyseal tumor. Tumors in this region are often over- Soft tissue tumors looked for inexcusably long periods because of the A desmoid tumor is a benign but very active soft tissue large soft tissue masses. This tumor is not all that rare in children and adolescents and The primary imaging technique is always the plain x- its treatment usually poses major problems. If the radiographic findings are unclear, a bone scan A rhabdomyosarcoma is the commonest malignant should be arranged. This cost-effective investigation can soft tissue tumor that affects this age group (⊡ Fig. Primary bone tumors of the pelvis, proximal femur and femoral shaft in children and adolescents (n=281) compared to adults (n=492). In the pelvic area, however, one should emerge from bone and spread into the surrounding soft also always consider the possibility of soft tissue tumors tissues with significant consequences. The MRI but also to the aneurysmal bone cyst, which commonly scan is essential for malignant processes. Conventional AP tomogram of the right hip of a 14-year patient with fibrous dysplasia and abnormal curvature of the femur old male patient with a chondroblastoma in the femoral head (»Shepherd’s crook deformity«) a b ⊡ Fig. MRI scan of an 8-year old girl with a large rhabdomyosarcoma in the gluteal muscles and resting on the iliac bone. Other benign tumors, also, rarely pose Although, in anatomical respects, the pelvis is formed therapeutic problems. Osteoblastomas must likewise be from the ilium, pubis and ischium, the following clas- thoroughly curetted. Osteochondromas should only be sification for the site of bone tumors has proved more removed if they 1) bother the patient, 2) are very large or effective since it is based on the needs of resection, recon- 3) change in size. In case of doubt, removal is indicated struction and function: since malignant degeneration occurs rather more fre- 3 ▬ iliosacral, quently close to the trunk compared to the extremities. Two-fifths of malignant tumors in each case are located in the first two regions, while the remaining fifth are located Malignant tumors in the ischiopubic area. The therapeutic strategies for the treatment of bone tu- mors are discussed in detail in chapter 4. Only the Proximal femur regional features will be mentioned at this point. Of the In the proximal femur we distinguish between the follow- malignant pelvic tumors that can occur in children and ing sites: epiphyseal (4%), epiphyseal/metaphyseal (15%), adolescents, Ewing’s sarcoma is the commonest. Since metaphyseal (49%), metaphyseal/diaphyseal (13%), epiph- these are usually very large by the time they are diag- yseal/metaphyseal/diaphyseal (4%), diaphyseal (15%; the nosed, the possibility of (micro-)metastases should be percentages in brackets relate to the distribution of 491 considered. As with other sites, chemotherapy is initially bone tumors of the proximal femur recorded by the Bone administered for 3 months. If imaging investigations and clinical examination do not show any reduction in the tumor mass, preirradiation Treatment of pelvic tumors may be considered. This possibility must be checked Benign tumors particularly if the tumor cannot be completely resected The common pelvic tumor of aneurysmal bone cyst is with a margin of healthy tissue because of its location (e. A dose of 30–40 Gy is admin- are rare if this procedure is performed with care. Vas- istered for the preirradiation, whereas 60–70 Gy would be cularized soft tissues, in particular, must be removed; required for irradiation of the tumor. Hyperthermia sensitizes the tumor for subsequent radiotherapy (and incidentally also for chemotherapy). The enthusiastic reports dating back to the 1980’s have not been followed up by more recent publications on sarcoma treatment. The drawback of irradiation is the subsequently increased bleeding ten- dency during resection and the increased postoperative infection risk. The option of preirradiation does not apply to osteo- sarcomas, nor can chemotherapy even be used in chon- drosarcomas. The surgeon should always aim for a wide resection, with the cut margins extending into healthy tissue.

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These ascending pathway nuclei are receptor atorlip-10 10mg fast delivery, the N-methyl-D-aspartate (NMDA) receptor discount atorlip-10 10mg otc, predominantly crossed and ascend in the anterolateral to become activated buy cheap atorlip-10 10mg on-line. NMDA receptors are also linked quadrant of the spinal cord contralateral to the cell to ion channels; however buy atorlip-10 10 mg mastercard, these channels allow influx body and the innervated body part generic atorlip-10 10 mg amex. Increased intracellular calcium leads to a magni- tion in tandem with nociceptive transmission; these fication of the incoming response, such that each pathways tend to be bilateral. In addition to ascending incoming signal results in successively more output pathways, intrinsic pathways in the spinal cord con- (“windup”). Many are multimodal and tissue injury, the allodynia or secondary hyperalgesia respond to both intense mechanical and thermal usually extends into uninjured tissue. Others respond exclusively to noxious heat or sensitivity is only to mechanical stimuli; thermal cold. There are also cells here that respond to only thresholds are usually unchanged distant from the chemical stimulation, including histamine release in injury site. A small population of One such cascade includes Ca2+ activation of nociception-specific cells are located in the deep dor- the enzyme phospholipase A2 (PLA2); this frees sal horn. This “classical” pathway projects to cyclooxygenase and results in the production of somatosensory (S1) cortex and is postulated to be prostaglandins. Prostaglandins (PGs) diffuse out of integral in sensory discrimination of pain, that is, the spinal neurons and back to the central terminal of where is it, is it sharp, is it hot, and so on. There, they act on specific PG receptors to posterior thalamus (VMpo); this nucleus, in turn, increase the amount of neurotransmitter released per projects to posterior insula cortex. Other recently been proposed to be a unique cortical pain enzymes, including nitric oxide synthase, are acti- center as well as to be involved in homeostatic control vated by Ca2+ in a similar manner, also resulting in a of the internal environment, including tissue integrity. This alternative hypothesis proposes that dorsal pos- Prostaglandins also act via specific PG receptors on terior insula rather than S1 cortex is the primary focus astrocytes to activate them and cause them to release of the sensory-discriminative aspect of pain. This area projects to the anterior cingulate that use of local anesthetics around the incision cortex. This medial pathway is likely to represent the (injury site) would block the high-frequency C-fiber motivational affective component of pain. Studies with maintained peripheral blockade of afferent input are under way. They bind to µ and κ opiate receptors on the central terminal of nociceptive pri- mary afferent fibers (presynaptic) and, by reducing Sorkin LS, Wallace MS. Surg Ca2+ entry when the action potential invades the ter- Clin North Am. Pain: Nociceptive and cally (on the dorsal horn neurons) to µ and δ opiate neuropathic mechanisms with clinical correlates. Aβ Yaksh TL, Lynch C, Zapol WM, Maze M, Biebuyck JF, fibers do not have presynaptic opiate receptors. This is one theory of why Aβ-mediated pain is relatively opiate resistant. Yaksh, PhD monoamines are released primarily from axons whose cell bodies are located in various branstem nuclei. Analgesic actions are potentiated by monoamine NERVE INJURY PAIN STATES reuptake (tricyclic antidepressants) inhibitors and are synergistic with morphine. There will be an initial dying back (retrograde chro- This increased ionic conductance may result in the matolysis) that proceeds for some interval at which increase in spontaneous activity that develops in a time the axon begins to sprout, sending growth sprouting axon. Collections of these proliferated growth cones form CHANGES IN AFFERENT TERMINAL SENSITIVITY structures called neuromas. DORSAL HORN REORGANIZATION This scenario is consistent with the observation that Following peripheral nerve injury, a variety of events following nerve injury, the postganglionic axons can occur in the dorsal horn which suggest altered pro- initiate excitation in the injured axon. Spinal Glutamate Release There is little doubt that the post-nerve injury pain state is dependent on an important role of spinal glu- EVOKED HYPERPATHIA tamate release. Nonneuronal Cells and Nerve Injury Following nerve injury (section or compression), Spinal Dynorphin there is a significant increase in activation of spinal Following peripheral nerve injury, there occur a wide microglia and astrocytes in spinal segments receiving variety of changes in the expression of dorsal horn input from the injured nerves. SYMPATHETIC DEPENDENCY OF NERVE INJURY PAIN STATE Loss of Intrinsic GABAergic/Glycinergic Inhibitory Control After peripheral nerve injury, there is increased inner- In the spinal dorsal horn are a large number of small vation of the peripheral neuroma by postganglionic interneurons that contain and release GABA and 19 sympathetic terminals. After nerve injury, spinal neurons may regress to The ability of low-threshold stimuli to evoke pain a neonatal phenotype in which GABA-A activation behavior after peripheral nerve injury has been a sub- becomes excitatory. Gunshot Bennett and Xie (four loose ligatures around the Wounds and Other Injuries of Nerves. Chemical sympathectomy Seltzer and Shir (hemiligation of the sciatic nerve) for neuropathic pain: does it work? Case report and system- Kim and Chung (tight ligation of the L5 and L6 30 atic literature review.

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Note the increased radiolucency of the right lung as a result of air trapping discount 10mg atorlip-10 otc. Radiographic technique for the chest and upper respiratory tract Plain film radiography remains the first-line examination for the majority of respiratory conditions 10 mg atorlip-10 fast delivery. However order atorlip-10 10 mg overnight delivery, alternative imaging modalities may be used to assess the extent of a disease or confirm a diagnosis (Box 4 order 10 mg atorlip-10 with mastercard. Its use is decreasing due to the recognition of high patient doses and the development of other imaging modalities buy generic atorlip-10 10mg on line. Ultrasound: Of little value for the respiratory system but extremely useful in the investigation of cardiac and mediastinal pathology. Computed tomography (CT): Second-line imaging modality after plain films. It provides good contrast and spatial resolution of lung parenchyma, mediastinum and bony structures but has the disadvantage that sedation is often required due to the length of examination. Magnetic resonance imaging (MRI): Useful for examining the mediastinum and the chest wall but has the disadvantage that young children will require sedation and frequently general anaes- thetic due to the relatively long imaging times. Scintigraphy: Of value in the investigation of pulmonary embolisms and bony pathology (e. Its use is on the decline as a result of improve- ments in ultrasound and MRI but it has the advantage of facilitating interventional procedures. Age (approximately) Projection Patient position Under 3 months Antero-posterior Supine 3 months to 4 years Antero-posterior Erect 4 years and older Postero-anterior Erect Choice of projection There is no difference in the diagnostic value of an antero-posterior (AP) pro- jection compared to the postero-anterior (PA) projection of the chest in a child less than 4 years of age as the thoracic cage is essentially cylindrical in young children and magnification of mediastinal organs is insignificant11. However, the AP projection is associated with a higher radiation dose to the developing breast, sternum and thyroid, and radiographers should take this into consideration when choosing the radiographic projection. In children under 4 years of age, the AP projection is often preferred due to ease of positioning, immobilisation and maintenance of patient communication. Young children like to see what is going on around them and positioning for an AP projection allows the child to watch the radiographer. A disadvantage of the AP projection is the likelihood of lordosis but this can be prevented by careful technique. This is particularly important if the child’s condition is being mon- itored radiographically as subtle radiographic changes in their condition may be difficult to interpret if the technical (positioning) factors are inconsistent. The fol- lowing descriptions of radiographic positioning are provided as a guide and may be modified depending upon equipment and accessories available. Antero-posterior (supine) The patient is positioned supine with the median sagittal plane at 90° to the image receptor. A 15° foam pad is placed under the upper chest and shoulders to prevent lordosis (Fig. The chin is raised and the arms are flexed and held on either side of the head to prevent rotation (Figs 4. Sandbags and lead rubber are placed over the hips and legs to provide immobilisation of the Fig. The cut out area helps although a 15° pad has been used, the extension of the to prevent the chin obscuring the upper patient’s arms will still result in a lordotic radiograph. Note the use of a 15° foam pad and arms positioned with elbows flexed to prevent hyperextension of the spine and lordosis. The primary beam should be centred to the area of interest thereby ensuring that effective collimation can be applied and dose reduction optimised. Antero-posterior (erect) This projection can be performed with the patient standing or seated erect. For younger children, correct positioning and immobilisation are easier to maintain with the child seated. It is important when seating a child to ensure that the legs are not extended level with the buttocks, as this will accentuate lordosis12 (Fig. Instead, a young child should be seated on a sponge/box thereby lower- ing the level of the legs and reducing lordosis (Fig. The patient is positioned initially with the posterior aspect of the chest in contact with a cassette. A 15° foam pad is then placed behind the upper chest and shoulders to prevent lordosis.

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Runners in short races (5K discount atorlip-10 10mg with mastercard, 10K order atorlip-10 10 mg without prescription, half-marathon) decreased salivary IgA an average of 27 cheap atorlip-10 10mg with amex. There was a negative correlation found running 16–26 mi a week increased the risk between salivary IgA levels and number of days of ill- of having ≥1 URI compared to running <9 mi a ness and flu symptoms order atorlip-10 10 mg online, but not days of cold symptoms cheap atorlip-10 10 mg visa. Running 9–16 mi or >26 mi a week con- Studies of immune marker changes with exercise have ferred intermediate risk. Moderate exercise lowers infection risk to below that of being sedentary, while strenuous In premenopausal women, no exercise or a 15-week exercise imposes the highest risk of all (Nieman, walking program made no difference in NK cell 2002). NKCA was significantly increased in the More evidence is needed, however, as the link training group at 6 weeks, but was elevated equally in between moderate exercise and infection is less clear both groups at 15 weeks. Most studies of infection 50% fewer days with URI symptoms, but the same and exercise are relatively small and rely on patient number of separate URIs compared to controls. Also, other fac- NKCA at 6 weeks was negatively correlated with URI tors such as pathogen exposure, stress, sleep, nutri- symptom days (Nieman et al, 1990b). The exercise group, however, had significantly fewer URIs than the control group (3/14 vs. A comparison group of elite elderly athletes had significantly higher NKCA and lymphocyte activity and even fewer URIs (1/12). NKCA and lymphocyte proliferative response were significantly higher in the rowers. Days of self-reported URI symptoms, however, were similar in both groups and did not correlate with immunologic changes. Transillumination and FEVER radiographs of the sinuses are generally not useful (Fagnan, 1998). Analgesics and decongestants in doses discussed all caloric and oxygen demand and insensible fluid above. Nasal saline rinses, 1/ tsp of table salt in 8 oz of 4 increased risk of injury (Brenner et al, 1984). Placing a warm washcloth over (650–1000 mg q 4–6 h) and nonsteroidal anti-inflam- the affected sinus and its corresponding nostril may matory drugs (NSAIDs) like ibuprofen (800 mg TID) also help. Sedating antihistamines are not recommended When an athlete is dehydrated, using NSAIDs during because they increase mucous viscosity and may exercise may reduce renal blood flow and precipitate impede sinus drainage. Antibiotics should cover the most common causative pathogens, Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarr- RHINORRHEA AND NASAL CONGESTION halis. Appropriate first-line choices include 10–14 day regimens of amoxicillin (500 mg TID), The most common complaints related to infections in and trimethoprim-sulfamethoxazole DS (one pill athletes are rhinorrhea and nasal congestion, most bid). Second-line choices include cefuroxime commonly seen with URIs and acute sinusitis. Typical findings include nasal mucosa edema and erythema, rhinorrhea, oropharyngeal erythema, and cervical lymphadenopathy. Oral or nasal decongestants can help relieve conges- Focusing treatment on the underlying infection, ces- tion, but side effects can include nervousness, insom- sation of smoking, and adequate hydration may pro- nia, tachycardia, and increased blood pressure. Sedating antihistamines are good choices for If the cough is especially irritating, however, cough sneezing and rhinorrhea as their anticholinergic medicines may be tried. Side effects can include sedation, dry such as codeine (10–30 mg q 3–4 h). It will suppress mouth, urinary retention, blurry vision, and consti- cough as well as provide sedation to help the pation (Levy and Kelly, 1999). Nonnarcotic options include dextromethorphan impair sweating and increase the risk of heat (10–20 mg q4h), benzonatate (100 mg TID), and exhaustion or heat stroke (Lillegard, Butcher, and guaifenesin (600–1200 mg bid) (Simon, 1995). Nasal ipratropium can provide the anticholinergic symptoms, but cough, productive or nonproductive, is effect of the nonsedating antihistamines without typically the most predominant feature (Levy and the systemic side effects. Atypical bacteria such as cators are unilateral sinus pain and tenderness, puru- Mycoplasma pneumonia and Chlamydia trachomatis lent rhinorrhea, lack of response to standard URI may also cause bronchitis in a small percentage of therapy, sinus pain with leaning forward, maxillary cases (Williamson, 1999). CHAPTER 31 INFECTIOUS DISEASE AND THE ATHLETE 177 Pulmonary findings are variable and can range from 7–14 days), an oral second-generation cephalosporin normal to diffuse rhonchi, and/or wheezing. Chest X- such as cefuroxime (250–500 mg bid for 7–14 days), rays are usually normal but may be useful to exclude amoxicillin/clavulanate (875 mg bid for 7–14 days), other diseases (Williamson, 1999).

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