By V. Gambal. Apache University.

CHAPTER 26 DERMATOLOGY 149 Kugler JP buy cheap erectafil 20 mg line erectile dysfunction high cholesterol, O’Connor FG erectafil 20 mg with amex how to get erectile dysfunction pills, 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). 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.

Because they can strongly affect cardiovascular function cheap 20 mg erectafil mastercard erectile dysfunction after 80, visceral motility cheap 20 mg erectafil visa impotence from smoking, and genitourinary function, emotions can have an important role in health overall and espe- cially in pain management. Simple negative emotional arousal can exacer- bate certain pain states such as sympathetically maintained pain, angina, and tension headache. It contributes significantly to musculoskeletal pain, pelvic pain, and other pain problems in some patients. Emotions are complex states of physiological arousal and awareness that im- pute positive or negative hedonic qualities to a stimulus (event) in the internal or external environment. A rich and complex literature exists on the nature of emotion, with many compet- ing perspectives. I cannot cover it here and instead offer what is necessarily an overly simplistic summary of the field, as I think it should apply to pain research and theory. One objective aspect of emotion is autonomically and hormonally medi- ated physiological arousal. The subjective aspects of emotion, “feelings,” are phenomena of consciousness. Emotion represents in consciousness the bi- ological importance or meaning of an event to the perceiver. Va- lence refers to the hedonic quality associated with an emotion: the positive or negative feeling attached to perception. Arousal refers to the degree of heightened activity in the central nervous system and autonomic nervous system associated with perception. Although emotions as a whole can be either positive or negative in valence, pain research addresses only negative emotion. Viewed as an emo- tion, pain represents threat to the biological, psychological, or social integ- rity of the person. In this respect, the emotional aspect of pain is a protec- tive response that normally contributes to adaptation and survival. If uncontrolled or poorly managed in patients with severe or prolonged pain, it produces suffering. Emotion and Evolution There are many frameworks for studying the psychology of emotion. I favor a sociobiological (evolutionary) framework because this way of thinking construes feeling states, related physiology, and behavior as mechanisms 3. Nature has equipped us with the capability for negative emotion for a purpose; bad feelings are not simply accidents of hu- man consciousness. They are protective mechanisms that normally serve us well, but, like uncontrolled pain, sustained and uncontrolled negative emotions can become pathological states that can produce both maladap- tive behavior and physiological pathology. By exploring the emotional dimension of pain from the sociobiological perspective, the reader may gain some insight about how to prevent or con- trol the negative affective aspect of pain, which fosters suffering. Unfortu- nately, implementing this perspective requires that we change conven- tional language habits that involve describing pain as a transient sensory event. I suggest the following: Pain is a compelling and emotionally negative state of the individual that has as its primary defining feature awareness of, and homeostatic adjustment to, tissue trauma. Emotions including the emotional dimension of pain characterize mam- mals exclusively, and they foster mammalian adaptation by making possi- ble complex behaviors and adaptations. Importantly, they play a strong role in consciousness and serve the function of producing and summarizing information that is important for selection among alternative behaviors. Ac- cording to MacLean (1990), emotions “impart subjective information that is instrumental in guiding behavior required for self-preservation and preser- vation of the species. Because negative emotion such as fear evolved to facilitate adapta- tion and survival, emotion plays an important defensive role. The ability to experience threat when encountering injurious events protects against life- threatening injury. Cognition and Emotion The strength of emotional arousal associated with an injury indicates, and expresses, the magnitude of perceived threat to the biological integrity of the person. Within the contents of consciousness, threat is a strong nega- tive feeling state and not a pure informational appraisal. In humans, threat- ening events such as injury that are not immediately present can exist as emotionally colored somatosensory images. Vi- sual images are familiar to everyone: We can readily imagine seeing things. We can also produce auditory images by imaging a familiar tune or taste im- ages by imaging sucking a lemon or tasting a familiar drink or food. Everyone can, for example, imagine the feeling of a full bladder, the sensation of a particular shoe on a foot, or a familiar muscle tension or a familiar ache. Interpretation of im- 64 CHAPMAN ages often takes the form of self-talk, which employs language.

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The changes usually affect the metaphyses and epiphy- This can be caused either by the abnormal tubular ab- ses cheap 20mg erectafil amex erectile dysfunction age statistics, and rarely the diaphyses (⊡ Fig purchase erectafil 20mg otc erectile dysfunction treatment yahoo. The condition is inherited and there are tarsal bones, although the long bones and pelvis can three forms: An X-linked dominant form (female:male = also be involved. The skull and spine are rarely af- 2:1), an autosomal-dominant form and an autosomal-re- fected. The disease is occasionally associated with This autosomal-dominant inherited disorder has a hypothyroidism, Turner syndrome and diabetes mellitus. The The bone changes generally produce no clinical signs treatment consists of the administration of high doses of or symptoms, although skin lesions occasionally occur parathyroid hormone. It results from a failure lateral, hyperostotic changes in the bone that resemble of the osteoclasts. The name is derived from the Greek persists, and the abnormal bone density is apparent on words melos = limb, extremity, and rhein = flow. Since melorhe- disease ostosis has also been observed in association with osteopoikilosis, it is thought that changes in the same gene are responsible for both disorders. Historical background, classification, etiology, occur- ▬ The bone changes are limited to dermatomes. The rence long bones are usually affected, while the skull, spine The condition was first described in 1904, shortly after and ribs are rarely altered. The disease can also occur the discovery of x-rays, by Heinrich Albers-Schönberg in a monostotic form. Nowadays, a variety of forms are distinguished osteosclerosis and osteofibrosis. Osteopetrosis also occurs in animals standpoint, pain is often present in the affected limb. Differing enzyme defects pre- Joint contractures can occur, principally in the hip and vail depending on the type of osteopetrosis involved 675 4 4. This leads to the paradoxical situation in which increased bone mass and bone softening are present at the same time, which explains the increased susceptibility to fractures. Another investigation found a prevalence of 50/million inhabitants, but the great majority of these cases involved the mild autosomal-dominant form. AP x-ray of the left hand of a 15-year old girl with osteopoi- fixed calcaneus position. Fractures, sandwich vertebrae, scoliosis, (Albers-Schönberg) coxarthrosis, osteomyelitis 676 4. In less than half of cases, delayed growth, Prognosis: Patients with the congenital malignant form fractures, deafness, osteomyelitis of the jaw, genu val- rarely reach adulthood, whereas those with the late- gum or varum and chest wall deformities are present. Around half ▬ In the late-onset form half of the patients remain as- of the cases progress asymptomatically, in which case ymptomatic. Around 40% suffer from spontane- the condition is diagnosed as a chance finding. The 4 ous fractures, while osteomyelitis of the jaw has been main problem in advanced age are the cases of prema- observed in 10% of cases, spontaneous bone pain in ture osteoarthritis. The following problems are of relevance to the ortho- and interferon. The transplantation of allogeneic paedist: bone pain, spontaneous fractures with poor hematopoietic stem cells seems to be a promising ap- healing, coxa vara , possibly genua vara or valga, proach [107]. Since the bones heal (spontaneously or after surgical treatments) and very poorly and cases of postoperative osteomyelitis are osteoarthritis (osteoarthritis of the hip or knee). One effective therapeutic method is medul- greatly increased bone density and medullary oblitera- lary nailing, although the surgeon must also ensure the tion. The metaphyses of the long bones frequently ap- greatest possible stability. Osteotomies may be needed pear coarsened, with closely-packed transverse bands, for the correction of severe deformities. The principal while longitudinal striae can be seen at the diaphyses orthopaedic problem, however, is the early onset of (⊡ Fig. Bands of increased bone density also osteoarthritis of the hip and knee, which must be man- arise in the vertebral bodies. The increased density aged with corresponding total prosthetic replacements. The fractures show poor healing with ab- Infantile cortical hyperostosis (Caffey disease) normal callus formation. Where possible, fractures This is a very rare, self-limiting condition of early child- should be treated conservatively. Toulouse-Lautrec), melorheostosis, sclerosteosis, pro- The gene locus is 1q41-q42. A congenital defect in the arterioles of the periosteum may be involved. The tibia and clavicles are less fre- quently affected, while there are only isolated reports of other bones being affected by this condition.

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Stramare R erectafil 20 mg mastercard erectile dysfunction treatment comparison, Tregnaghi A trusted 20mg erectafil buying erectile dysfunction pills online, Fitta C, et al (2004) High-sensi- to texts on soft tissue tumours. An algorithm tivity power Doppler imaging of normal superficial lymph for the diagnostic imaging of a soft tissue lump in a nodes. Steinkamp HJ, Wissgott C, Rademaker J, et al (2002) Cur- rent status of power Doppler and color Doppler sonogra- phy in the differential diagnosis of lymph node lesions. Moore SW, Schneider JW, Schaaf HS (2004) Diagnostic One group has reported the potential for looking at aspects of cervical lymphadenopathy in children in the colour Doppler in tumours to assess response to che- developing world: A study of 1877 surgical specimens. They showed a reduction in the colour Pediatr Surg Int 19:240-244, (June), 2003. J Pediatr Surg Doppler signal in those patients who showed a good 39(7):1150 Lump ULTRASOUND Cystic Solid Complex, No lipoma ganglion, cyst, haematoma diagnosis muscle hernia CD US unsure AVM, MRI yes MRI Benign Haemangioma lesion Repeat US Unsure diagnosis yes Benign reassure diagnosis Fig. Algorithm for imaging a Biopsy Unsure diagnosis soft tissue lump in a child Soft Tissue Tumours in Children 83 7. Desandes E, Lacour B, Sommelet D, et al (2004) Cancer inci- (2000) Histopathology of vascular lesions found in Kasa- dence among adolescents in France. Nahm WK, Moise S, Eichenfield LF, et al (2004) Venous mal- Opin Pediatr 16(5):508–514 formations in blue rubber bleb nevus syndrome: variable 10. Lamps LW, Scott MA (2004) Cat-scratch disease: historic, onset of presentation. Ortega R, Fessell DP, Jacobson JA, et al (2002) Sonography Med Surg 23(2):87–98 of ankle ganglia with pathologic correlation in 10 pediat- 28. Paltiel HJ, Burrows PE, Kozakewich HP, et al (2000) Soft- ric and adult patients. AJR Am J Roentgenol 178(6):1445– tissue vascular anomalies: utility of US for diagnosis. Robben SG (2004) Ultrasonography of musculoskeletal sonography in the study of prevalence and clinical evolu- infections in children. Eur Radiol Jan 30 (Epub ahead of tion of popliteal cysts in children with knee effusions. Seil R, Rupp S, Jochum P, et al (1999) Prevalence of popliteal Roentgenol 180(2):395–399 cysts in children. Siegel MJ (2001) Magnetic resonance imaging of mus- literature) Arch Orthop Trauma Surg 119(1–2):73–75 culoskeletal soft tissue masses. Massari L, Faccini R, Lupi L, et al (1990) Diagnosis and 39(4):701–720 treatment of popliteal cysts. Saifuddin A, Burnett SJ, Mitchell R (1998) Pictorial review: 252 ultrasonography of primary bone tumours. Lang IM, Hughes DG, Williamson JB, et al (1997) MRI 53(4):239–246 appearance of popliteal cysts in childhood. Woertler K, Lindner N, Gosheger G, et al (2000) Osteochon- 27(2):130–132 droma: MR imaging of tumor-related complications. Fornage BD, Tassin GB (1991) Sonographic appearances of Radiol 10(5):832–840 superficial soft tissue lipomas. Rubens DJ, Fultz PJ, Gottlieb RH, et al (1997) Effective ultra- 220 sonographically guided intervention for diagnosis of mus- 17. Inampudi P, Jacobson JA, Fessell DP, et al (2004) Soft-tissue culoskeletal lesions. J Ultrasound Med 16(12):831–842 lipomas: accuracy of sonography in diagnosis with patho- 35. Radiology 233(3):763–767 graphically guided core needle biopsy of bone and soft 18. Miller GG, Yanchar NL, Magee JF, et al (1998) Lipoblastoma 16(5–6):458–461 and liposarcoma in children: an analysis of 9 cases and a 19. Giovagnorio F, Valentini C, Paonessa A (2003) High-reso- review of the literature. Can J Surg 41(6):455–458 lution and color doppler sonography in the evaluation of 37. Bramer JA, Gubler FM, Maas M, et al (2004) Colour Doppler 178(3):557–562 ultrasound predicts chemotherapy response, but not sur- 22. Laor T (2004) MR imaging of soft tissue tumors and tumor- vival in paediatric osteosarcoma. Torabi M, Aquino SL, Harisinghani MG (2004) Current Am Acad Dermatol 48(4):477–493; quiz 494–496 concepts in lymph node imaging. Alvarez-Mendoza A, Lourdes TS, Ridaura-Sanz C, et al 1518 Interventional Techniques 85 6 Interventional Techniques David Wilson CONTENTS stances are in suspected tumours of bone or soft tissue and when the nature and type of infection is 6. From the imaging the biopsy may be great advantages of limiting the extent of tissue planned.

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In 2000 erectafil 20 mg without a prescription erectile dysfunction at age 31, Paley developed a method for predicting the adult height of children of various ages erectafil 20mg online erectile dysfunction free samples. This “multiplier” method is currently the most accurate formula available (Table 1. Chapter 2 Low er extrem ity developm ental attitudes in infancy and early childhood If we cannot alter the natural history of a condition, then it is perhaps wise to spare the patient the consequences of our attempts. Normal attitudes of the lower extremities (birth to 18 months) It is surprising how common it is for parents to seek medical attention for “apparent” deformities of the lower extremities from birth to 18 months of age. Undoubtedly, as physicians, we have done a less than adequate job in educating parents as to the “normal” lower extremity attitudes in young children. At birth, following a cephalic or breech delivery, the hips will characteristically lie in flexion with a flexion contracture commonly of 30–60 degrees (Figure 2. Likewise, a knee flexion contracture of 20–45 degrees is not at all uncommon, except following a frank breech delivery. There are usually 10–30 degrees of internal tibial torsion, and the position of the Figure 2. The degree of knee and hip joint contracture commonly seen at foot and ankle will be a direct reflection of birth. Consequently, equinovarus, equinovalgus, calcaneovalgus, and calcaneovarus are all normal accompaniments providing that the deformity is fully flexible and passively correctable beyond the neutral position. Intrauterine postural deformities secondary to normal intrauterine compression will generally unwind and spontaneously correct, usually by three months of age, in well over 90 percent of all children. Treatment of these deformities by Lower extremity developmental attitudes 10 parental positioning, stretching, splints, casts, or braces will be universally successful, with little more scientific merit than having the parents pay periodic visits to the zoo until the child is four months of age. Although hip contracture generally spontaneously improves, a mild contracture of 15–20 degrees is common even at six to nine months of age, until the child begins standing through much of his or her waking day. Likewise, the knee contracture will unwind, although full straightening is uncommon until standing is achieved. Internal tibial torsion also will spontaneously improve (this process will be covered in a later discussion). Intrauterine foot and ankle deformation has an identical evolution, with flexibility increasing rapidly through the first three months of extrauterine life. The 10–15 percent of children who persist beyond that age with contracture will be dealt with subsequently. It is conceptually easy to envision the rationale for these postural attitudes. There is little necessity for “straight” hips, knees, ankles, and feet in a child who is rolling over, sitting, and crawling. When “mother nature” determines that it is time to stand and eventually walk, the bones and joints will then allow for that attitude without our interference. Out-toeing Nearly 90 percent of all adults who have been clinically measured will have zero to ten degrees of out-toeing as a part of their normal gait pattern. So common is this complaint seen by primary care physicians and pediatric orthopedists, that I have devoted a separate discussion to the topic. At birth, nearly all children have 70–90 degrees of passive and active external rotation of the hip, regardless of the degree of hip flexion contracture. The normal crowded intrauterine position does not allow the infant to “stand up,” or to internally rotate the lower limbs. Consequently, external 11 Out-toeing rotation at the hip level is the “norm” and this contracture deformation persists until it is no longer needed. There is little need for internal rotation of the hip until children begin to crawl and particularly until they begin to stand. Lower limbs that are externally rotated and abducted are helpful for initially achieving appropriate standing balance and stability. Considering the needs that our body has for the age that we are, it is amazing that we are “lined up and ready to go” when we achieve that next developmental milestone. Just as a mechanical engineer would design a modern sports car for stability and balance by lowering the center of gravity and widening its base, so do we humans spread our legs (widen the base), externally rotate our hips, crouch or squat (lower our center of gravity), and even pronate or “inroll” our ankles to achieve a maximally stable weight bearing surface for our feet (Figure 2. Nearly every grandmother will recognise this posture, as all of her “normal” grandchildren will have demonstrated it when they began to stand and walk. Developmental displacement of the hips (formerly termed congenital dislocation of the hip), congenital coxa vara, partial absence of the femur, and neurologic disorders of the lower extremity are uncommon causes of external rotation that should be considered. However, a properly conducted history and physical, and perhaps a radiograph if clearly clinically indicated, will establish the benign nature of the observation. In addition to the expense of unnecessary braces, splints, and adaptive shoe wear to treat this condition, there is a psychological impact of implanting within families’ minds the idea that their “loved one” is “diseased,” and this should provide adequate caution to all of us. There is nothing medically demeaning in simply reassuring the family, particularly when the consequences of treatment will only perpetuate the fallacy. Lower extremity developmental attitudes 12 Genu varum (“bowlegs”) and genu valgum (“knock-knees”) From the 1940s to the present, “bowlegs” and “knock-knees” have enjoyed the distinction of being one of the most common complaints seen by primary care physicians and orthopedic surgeons. A far greater understanding of the natural evolution of these conditions in childhood has resulted in a dramatic reduction in the number of these cases currently seen by physicians. In addressing the natural history of these two conditions in the growing child, it is important Figure 2.

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