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The correction of secondary hallux also frequently occurs in middle age in people who walk varus due to supination of the forefoot is addressed in barefoot generic zocor 10mg on-line. Since the ball of the great toe cannot provide support purchase 20mg zocor, the great toe is drawn inward until it is able to 3 buy zocor 40mg otc. Clinical features quality zocor 10mg, diagnosis The diagnosis is confirmed by clinical examination: The great toe deviates medially to a greater or lesser extent Occurrence (⊡ Fig 40 mg zocor with mastercard. Just putting on the whole foot are affected, there may be an underlying the shoe can cause problems, and pressure points can also disease such as neurofibromatosis, Proteus syndrome or occur over the tip of the toe or the interphalangeal joint. If no callus has formed under the ball of the great toe, then the hallux Clinical features, diagnosis varus is secondary and not congenital. The treatment of congenital hallux varus is always sur- The bone structures are unchanged provided no addi- gical. The aim is to restore the normal axis of the great tional malformations are present. Congenital hallux varus in an 8-year old boy with dys- plasia of the 1st metatarsal and synostosis between the 1st and 2nd metatarsals. Differing > Definition shoe sizes often have to be worn on the left and right foot. Additional muscles in the retromalleolar region as acces- The orthotist must fill the gap in front of the normally sory muscle bellies of the flexor digitorum longus, flexor growing toes with padding, otherwise the shoe will not hallucis accessorius longus or soleus accessorius muscles. A greatly enlarged toe can be made smaller These are normal congenital variants. The fatty tissue on one side is removed, Occurrence and the toe is fused with the adjacent toe. In the second Two studies with cadavers have shown an incidence of step, the fatty tissue on the other side is removed. Amputation should be avoided as a rule, otherwise axial deviation of the adjacent toes can occur, which can also Clinical features, diagnosis lead to symptoms. Clinical examination reveals an asymptomatic thickening in the hollow alongside the Achilles tendon. Occurrence The shortening of a single metatarsal in isolation is not Treatment all that rare. No Since this is a normal variant without any pathological epidemiological data are available however. The combination of femoral hypoplasia or a proximal focal femoral deficiency ( Chapter 3. In of the great toe bears most of the weight during this ma- the much more common fibular deficiency, the 5th ray neuver. If the metatarsal is too short, the weight cannot alone may be missing or several rays from the lateral roll correctly over the ball of the great toe. Because of the the middle rays can also impair the transverse arch and malformed fibula, instability and valgus deviation of occasionally cause symptoms. In the much rarer condi- Treatment tion of tibial deficiency, the 1st ray, or several rays from If the heel-to-toe roll mechanism is impaired and symp- the medial to lateral side may be missing. However, the Occurrence extent of the lengthening should not exceed 40% of The incidence of fibular deficiency was calculated to be the length of the metatarsal, otherwise there will be 2:100,000 neonates in one epidemiological study, a high risk of stiffening of the metatarsophalangeal although far from all patients show foot abnormalities in joint. If the fibula is completely absent and if no more than 3 At birth the foot is usually in an equinovalgus position and lateral foot rays exist then preservation of the foot is not one or more lateral rays of the foot are missing. In such cases the patients should structures of the rearfoot may be incompletely formed and be gently encouraged to agree to a Syme amputation tarsal coalition is present. In this anomaly the foot is in a varus-equinus is usually extremely difficult, since muscle tension always position. The x-ray shows the defectively formed bone tends to cause the talus to subluxate laterally. If good heel structures and the bone connection if tarsal coalition is control can be achieved it is generally possible to guide present (⊡ Fig. The latter is very commonly seen in the foot to a certain extent and place it in the orthosis longitudinal deficiency of the fibula, as is the formation of in an equinus position. If an attempt is made to put the a congenital ball-and-socket ankle joint [5, 47]. If the foot Treatment can be preserved until the completion of growth, a stable The main problem associated with fibular deficiency is plantigrade foot position can then be achieved with an stabilization of the ankle. If a type I B or type II fibular arthrodesis of the ankle joint (or possibly a triple arthrod- ⊡ Fig.

Until a consensus on the meaning of author order is achieved zocor 10mg mastercard, researchers who strive to gain recognition for their own intellectual contribution whilst mentoring junior staff in the processes of writing and publication will always be disadvantaged discount 10 mg zocor with mastercard. To deal with this issue 40 mg zocor with visa, researchers applying for promotion often specify the exact contributions that they made to publications listed in their curriculum vitae order zocor 40 mg online. Gift buy zocor 40 mg amex, ghost, and guest authors Ghost writing is what you do for a football player when it is painfully obvious from his every utterance on and off the field that he has little to say but still needs help to say it. David Sharp55 “Gift” authorship occurs when someone who has not made an intellectual contribution to a paper accepts an authorship. This type of authorship often develops because both the author and the “gift” author benefit from the relationship. Senior “gift” authors are often enrolled because they tend to confer a stamp of authority on a paper. Many researchers are willing to cite senior authors if they think that this will facilitate the publication of their work or enhance their career prospects. Most of all, gift authors should definitely not be included “because everyone does it”. In a survey of journal articles published in three peer-reviewed journals (Annals of Internal Medicine, JAMA, and the New England Journal of Medicine) in 1996, 11% of articles involved the use of ghost authors and 19% had evidence of honorary authors. Although “guest” authors may have final control over the manuscript, they may not thoroughly review the paper if it does not have high priority in their workload. Given that science must be based on truth and trust, practices of “gift” and “ghost” authorship are to be avoided at all costs. CF Wooley61 The issues of whether, and how, contributors other than the authors of a paper should be listed and have their role acknowledged continues to be debated. This issue becomes especially problematic in the case of large multicentre trials. As a result, there has been a move towards some papers including guarantors and contributors instead of authors62 and some journals now publish a byline disclosure of multicentre trials with a list of clinicians and study-organisation contributors, and a statement of the contribution of each author. A move to naming “contributors” rather than authors was suggested to improve both the credibility and the accountability of authorship lists62 and some large multicentre studies have adopted this approach. Journals such as the Lancet and the BMJ now list the contributions of researchers to some 41 Scientific Writing journal articles, often when the number of authors exceeds a prespecified threshold. However, in JAMA and in other journals, studies are often published with more than 40 authors who are listed in alphabetical order. Whereas some journal editors and readers see long lists of contributors as a way to reward and encourage researchers, others see it as wasted space. When the review is submitted, contributors are asked to describe in their own words their exact role in the review and this statement of contribution is then made available to readers. By defining the roles that constitute contribution rather than authorship, the Cochrane Collaboration have gone some way to helping solve authorship problems and ensuring that contributors are acknowledged appropriately. Alastair Spence63 Deciding who to formally acknowledge in your paper requires almost as much consideration as deciding authorship and contribution, although the criteria are less contentious. Basically, all research and support staff who make a direct contribution to a study but who do not fulfil the criteria for authorship or contributorship should be granted a formal acknowledgement. Some journals require that people who are named in this section give permission to be acknowledged, preferably in writing, and that their specific contribution is described. If someone in the team has made a fundamental contribution to your study, it is naturally polite to acknowledge this contribution in a formal way. Financial interests that may pose a conflict of interest To decide whether to include your coworkers as authors, contributors, or acknowledgements, you can consult the Vancouver Group’s criteria that are published under the ICMJE acronym. To limit the size of the acknowledgement list, the New England Journal of Medicine has developed a policy of 43 Scientific Writing publishing only a list that can fit into a single print column64; however, the acknowledgement pages in the Lancet are sometimes longer than one full page. Acknowledgements King quotes have been reprinted with the permission of Scribner, a Division of Simon & Schuster, Inc. The Lil and Maxwell quote has been produced with permission from Horvitz, LA ed. Call for comments on a proposal to improve reporting of clinical trials in the biomedical literature. Confusing conclusions and the clinician: An approach to evaluating case-control studies. Publication bias: evidence of delayed publication in a cohort study of clinical research projects.

In our experience generic zocor 40 mg, cross striations are ploration of the tumor cavity is required buy 40 mg zocor. Generous very rarely present and usually occur in more oblong biopsies can yield information about the completeness cells containing more cytoplasm generic 20 mg zocor visa. They are read- of tumor destruction and the resection and the need ily recognizable however under the electron micro- for further resection purchase 40 mg zocor. The spindle cell rhabdomyosarcoma is considered Synovial sarcoma to be the embryonal type with the better prognosis discount zocor 10mg with mastercard. This biphasic tumor consists of (predominantly) fibro- The alveolar form involves weakly differentiated tu- blastic and epithelioid sections. After rhabdomyosarcoma mor cell aggregates in which »alveolar« spaces can this is the second commonest malignant soft tissue tumor form as a result of the loss of cohesion of the tumor encountered during adolescence, occurring mainly be- cells. They regularly show the translocation occurring in contact with tendons, tendon sheaths or t(2;13)(q 37;q 14). During immunohistochemi- bursae, and occasionally with ligaments, aponeuroses cal testing the tumor cells react with muscle-specific or fasciae, and preferably affect the lower extremity, markers. The embryonal type has the best prognosis the tumor grows fairly slowly it is not usually di-. On the x-ray calcifications are seen more fre- postoperative chemotherapy and wide resection [9, quently compared to other sarcomas (in around 40% 18]. Provided the tumors are lo- more intense than that of muscle, but weaker than cated in relatively favorable sites, a five-year survival that of fatty tissue. The Histologically a distinction is made between biphasic rhabdomyosarcoma is the malignant soft tissue tu- and monophasic (purely epithelioid or fibroblastic) or mor that best responds to chemotherapy. The classical biphasic has not proved possible to resect the tumor with a type shows spindle-shaped fibroblasts with moderate margin of healthy tissue, the tumor bed and regional atypia and usually few mitoses. Radiotherapy also swirls or strands of fairly large cells rich in cytoplasm, has drawbacks however. Secondary tumors are not readily discernible borders and vesicular nuclei. MRI scans of an alveolar rhabdomyosarcoma in the medioposterior femoral muscles of an 18-year old girl. In view of the good primary ▬ Prognosis: Synovial sarcomas have a marked tendency prognosis, radiotherapy and chemotherapy is appro- to recur and metastasize, although it can take a long priate only for non-radically resectable or metastasiz- time for the metastases to appear since the tumor ing tumors. Consequently, the five-year sur- vival rate is not sufficient for evaluating the success of Malignant peripheral nerve sheath tumor (MPNST) treatment, and the result can only be evaluated after (schwannoma) 10 years. The initial size of the tumor has a significant Malignant peripheral nerve sheath tumor (MPNST) predictive value. It occurs as a solitary tumor ▬ The treatment consists of a wide resection with in adolescents principally in connection with von Reck- subsequent polychemotherapy and radiotherapy [14, linghausen disease. The regional lymph nodes should also be re- white tumors, usually in connection with a peripheral moved. Extraskeletal Ewing sarcoma Since the tumors spread along the nerves the surgical This tumor is much rarer than the osseous form of Ewing procedure can prove problematic. Isolated limb perfusion with specific chemotherapeu- ▬ Histologically it is indistinguishable from the intraos- tic agents (tumor necrosis factor«) can prove success- seous Ewing sarcoma. Infantile fibrosarcoma Fibrosarcoma mainly affects adult patients over 30 years of age and is rare in children. Congenital cases do exist, however, and these infantile or congenital fibrosarcomas usually occur during the first 12 months of life, particu- larly in male patients, and are located predominantly on the distal parts of the extremities. The more collagen the tumor contains the more it resembles the adult type of fibrosarcoma. Both forms show numerous mitoses, an important differential diagnostic criterion, in dis- tinguishing them from fibromatoses. In contrast with the adult form, lymphocytic infiltrates are often pres- ⊡ Fig. MRI scan of amalignant peripheral nerve sheath tumorin an ent, as are highly vascular hemangiopericytoma-like 11-year old girl, originating from the sacral nerve roots and spreading sections. Bhattacharya B, Dilworth HP, Iacobuzio-Donahue C, Ricci F, Weber children: prognosis and management. Paediatr Drugs 4 (1): 21–8 K, Furlong MA, Fisher C, Montgomery E (2005) Nuclear beta- 22. Lackner H, Urban C, Benesch M, Raith J, Moser A, Sovinz P, catenin expression distinguishes deep fibromatosis from other Schwinger W, Dornbusch HJ, Triebl-Roth K (2004) Multimodal benign and malignant fibroblastic and myofibroblastic lesions. Breneman J, Lyden E, Pappo A, Link M, Anderson J, Parham D, Hematol Oncol.

Even though society may ascribe certain positive qualities to dwarfs there is no doubt that small stature is Rumpelstiltskin associated with considerable psychological problems for those affected purchase zocor 20mg with mastercard. If we were all small then small people would not have any particular problems cheap 40mg zocor free shipping. In a study of young people aged between 14 and 20 with heights between 85 cm (2 ft 9 in) and 150 cm (4 ft 11) order 20 mg zocor free shipping, 85% did not consider themselves to be disabled order zocor 20 mg mastercard. Very small individuals experience restrictions in their every- day lives because they are unable to reach light switches order zocor 20 mg, elevator buttons, washbasins or shop counters, but these functional handicaps can at least be minimized by practi- cal appliances and a certain amount of creativity. Of much greater consequence and far more difficult to cope with is the »social handicap«: the stigmatization based solely on a difference in height. The fact that other people turn round and stare, almost as a reflex action, simply because one is particularly short. The fact that small individuals automatically become the center of at- tention whenever they venture into the outside world: on Dwarf Long-Nose the street, in restaurants, on public transport, everywhere. The reactions they encounter range from astonishment, insecure or very unusual behavior, sympathy, mockery extending to maliciousness, depending on the maturity of the onlooker. Height therefore appears to play an extremely impor- tant role in our society. A study by an anthropologist investigating the connection between shortness and tall- ness with properties that are attributed to them showed that a tall person was considered to be healthier, stron- ger, more interesting, more serious, more active, safer, tougher and more open than a short person. This range of properties is also commonly ascribed to suc- cessful individuals. In this context, the wish of many small people to be made taller with the help of advances in modern medicine is perfectly understandable. Many are prepared to invest a great deal of time and effort and Quasimodo tolerate considerable pain in order to achieve their goal. Associations of little people resolving the problem than a distressing bilateral leg exist in many countries of the world. For parents the realization that the child’s growth will » small is beautiful... The way in which this »crisis« is managed is hugely important for the child’s future. The greater the parents’ self reproach, the greater Classification the risk that the child will be spoilt and incapable, in later Classifying such a heterogeneous group as the congenital life, of living independently despite having the necessary disorders of the musculoskeletal system is not a simple intellectual abilities. But such a classification is needed in order treating doctors to avoid stirring up any feelings of guilt to create a common basis for professional discussions. The family and pregnancy The »Committee on Nomenclature on Intrinsic Diseases history must be taken with extreme sensitivity. Specific of Bones« of the European Society of Paediatric Radiology details should only be questioned if they are actually rel- was the first body to undertake this classification in 1971 evant to the diagnostic process. Seemingly trivial routine (»Paris Nomenclature«), which has since been revised questions (such as the administration of drugs or the several times, most recently in 2001. This primarily drinking of alcohol during pregnancy) can very easily clinically oriented classification was recently restructured lead to lifelong (unjustified) self reproach on the part of to take account of the findings of molecular genetics the mother. This international classification currently comprises 36 groups, including 33 with generalized disorders (os- » Childhood illnesses of the soul first manifest teochondrodysplasias) and 3 with localized deficiencies themselves in adults « (dysostoses). While the gene defect in most disorders is (Hans Weigel) already known [2, 5, 8], the gene product still remains Many patients with hereditary illnesses are perfectly nor- unclear in many cases. Some may show outstanding ar- of genetics, these gaps are also expected to be closed in tistic talent. The recently deceased Michel Petrucciani, whose »Committee on Nomenclature on Intrinsic Diseases small stature was associated with osteogenesis imperfecta, of Bones« was one of the greatest jazz pianists of this time. Even Osteochondrodysplasias the powerful figures of the world were not always tall and 1. Attila, the king of the Huns, King Charles III of Thanatophoric dysplasia Naples and Sicily and Napoleon were all said to be small Achondroplasia in stature. Short-rib dysplasias ▬ Asphyxiating thoracic dysplasia (Jeune syn- drome) ▬ Chondroectodermal dysplasia (Ellis-van-Creveld syndrome) 5. Type II collagenopathies ▬ Achondrogenesis II and hypochondrogenesis ▬ Spondyloepiphyseal dysplasia ▬ Kniest syndrome ▬ Stickler syndrome 648 4. Type XI collagenopathies Maffucci syndrome ▬ Otospondylomegaepiphyseal dysplasias Fibrous dysplasia, (monostotic, polyostotic, Mc- 10. Multiple epiphyseal dysplasia Fibrodysplasia ossificans progressiva ▬ Multiple epiphyseal dysplasia Cherubism ▬ Pseudoachondroplasia 32.

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