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More rarely seen over the long term cheap zenegra 100mg mastercard, however 100 mg zenegra overnight delivery, are Phalanges: closed reduction under regional anesthesia signs of arthritis which, in turn, correlate poorly with the for displaced fractures, followed by immobilization with clinical findings. For fractures of the great toe the fit- We have observed pseudarthroses particularly after ting of a below-knee splint may be advisable to avoid any the conservative treatment of displaced fractures of the stubbing. Displaced intra-articular fractures (particularly base phalanx of the great toe and after displaced condylar condylar fractures) must be reduced openly to an ana- avulsions, less frequently after fractures of the base of the tomical position and fixed. If corresponding symptoms are present, open reduction with trimming of the fragments and stable Immobilization period internal fixation is indicated. Calcaneal and talar fractures: 6 weeks, or possibly lon- ger depending on the radiological result. Berson L, Davidson RS, Dormans JP, Drummond DS, Gregg JR Follow-up controls (2000) Growth disturbances after distal tibial physeal fractures. Consolidation may be assessed clinically since the foot Foot Ankle Int 21: 54–8 skeleton can be palpated directly at any point. Radiology 179: 93–4 tient is free of pain, he or she may proceed to full weight- 4. J Bone Joint Surg (Br) 82: 211–6 only justified in the following situations: 5. Buoncristiani AM, Manos RE, Mills WJ (2001) Plantar-flexion ▬ posttraumatic, troublesome deformities, which may tarsometatarsal joint injuries in children. Champagne IM, Cook DL, Kestner SC, Pontisso JA, Siesel KJ ▬ rare, epiphyseal fractures which, because of the pos- (1999) Os subfibulare. J Am sibility of an inhibiting growth disturbance, should be Podiatr Assoc 89: 520–4 followed up for 2 years, 7. Ferran J, Blanc T (2001) Os subfibulare in children secondary to ▬ Talar fractures in view of the risk of avascular necro- an osteochondral fracture. Grace DL (1983) Irreducible fracture – separations of the distal tibial epiphysis. Jarvis JG, Miyanji F (2001) The complex triplane fracture: ipsilat- Complications eral tibial shaft and distal triplane fracture. J Trauma 51: 714–6 Posttraumatic deformities: Persisting volar tilts after meta- 10. Kensinger DR, Guille JT, Horn BD, Herman MJ (2001) The stubbed tarsal or phalangeal fractures can hinder walking. Varus great toe: importance of early recognition and treatment of and valgus deformities and rotational defects can result in open fractures of the distal phalanx. Leibner ED, Simanovsky N, Abu-Sneinah K, Nyska M, Porat S the problem of overlapping toes. J Detecting a threatened or established compartment Pediatr Orthop 10: 68–72 syndrome requires considerable alertness on the part of 12. Mora S, Thordarson DB, Zionts LE (2001) Pediatric calcaneal frac- the examiner, particularly in patients presenting with tures. Foot Ankle Int 22: 471–7 only slight forefoot swelling initially directly after a crush 13. Owen RJ, Hickey FG, Finlay DB (1995) A study of metatarsal frac- tures in children. Phan VC, Wroten E, Yngve DA (2002) Foot progression angle after in a below-knee cast and elevation with close, clinical distal tibial physeal fractures. Rammelt S, Zwipp H, Gavlik JM (2000) Avascular necrosis after Avascular necrosis is observed in 15–20% of childhood minimally displaced talus fractures in a child. Foot Ankle Int 21: talar neck fractures, even including undisplaced fractures. Vienne P, Schöttle P (2003) Die chronische Rückfußinstabilität: Failure to spot the injury initially and an age of under neue Konzepte in der Diagnostik und in der chirurgischen Be- 9 years are risk factors. Schweiz Z Sportmed Sporttraumatol 51: 107–11 radiological displacement on the trauma x-rays does not rule out the possibility of shifting during the trauma fol- lowed by spontaneous reduction, the risk of a circulatory impairment is not reduced. Osteomyelitis occurs after trivialized open fractures of the great toe that have received inadequate initial treat- ment. Etiology, frequency and site The foot is typically susceptible to exogenous infec- Infections of the foot and ankle have their own distinctive tions, e. The circula- for example) or if congenital or acquired sensory dis- tion is poorer and the temperature lower than in other orders are present in the lower limbs.

Atrial fibrillation discount zenegra 100 mg mastercard, or involuntary zenegra 100 mg line, irregular muscular contractions of the atrial myocardium, is the most common chronic arrhyth- mia; it occurs in rheumatic heart disease, dilated cardiomyopathy, atrial septal defect, hypertension, mitral valve prolapse, and hypertrophic cardiomy- opathy. Ventricular fibrillation, or involuntary con- tractions of the ventricular muscle, is a frequent cause of cardiac arrest. Heart block is a disorder of the heartbeat caused by an interruption in the pas- sages of impulses through the heart’s electrical sys- tem. Causes include CAD, hypertension, myocardi- tis, overdose of cardiac medications (such as digi- talis), and aging. Arteriosclerosis represents a group of diseases characterized by thickening and loss of elasticity of the arterial walls, often referred to as hardening of the arteries. There are 3 types of AMC: contracture syndromes, amyoplasia (ie, lack of muscle formation), and distal arthrogrypo- sis, primarily affecting the hands and feet. Diseases, Pathologies, and Syndromes Defined 383 ascites: An abnormal accumulation of serous (edema- tous) fluid within the peritoneal cavity, the poten- tial space between the lining of the liver, and the lining of the abdominal cavity. It is most often caused by cirrhosis, but other diseases associated with ascites include heart failure, constrictive peri- carditis, abdominal malignancies, nephrotic syn- drome, and malnutrition. The body fails to distinguish self from nonself, causing the immune system to direct immune responses against normal (ie, self) tissue and become self-destructive. A slight variation in the shape or structure of the mitral valve causes prolapse. This syndrome is also referred to as floppy valve syndrome or click-murmur syndrome. This type of carcinoma rarely metastasizes beyond the skin and does not invade blood or lymph vessels but can cause significant local damage. If the basilar artery is occluded, the brainstem symptoms are bilateral. When a branch of the basilar artery is occluded, the symptoms are unilateral, involving sensory and motor aspects of the cranial nerves. Diseases, Pathologies, and Syndromes Defined 385 Bell’s palsy: Facial paralysis due to a functional disor- der of the seventh cranial nerve. Etiology is uncertain, although it is suggested that it occurs as an inflammatory response in the audi- tory canal. Any agent that causes inflammation and swelling creates a compression that initially causes demyelination. Secondary biliary cirrho- sis can occur with prolonged, partial, or complete obstruction of the common bile duct or its branches. It is often caused by the ingestion of neurotoxins in food that resist gastric digestion and proteolytic enzymes and are readily absorbed into the blood from the proximal small intestine. Common symptoms are gaze palsies, a loss of active control of eye movement; nystagmus, involving rhythmic tremor of the eye; and dysarthria, abnormal speech resulting from poor control of the muscles of speech. Most breast carcinomas are adenocarcinomas derived from the glandular epithelium of the terminal duct lobular unit. There is chronic dilation of the bronchi and bron- chioles that develops when the supporting struc- tures (ie, bronchial walls) are weakened by chronic inflammatory changes associated with secondary infection. Brown-Séquard’s syndrome: A set of symptoms, caused by a primary intraspinal tumor, in which there is nerve root pain followed by motor weak- ness and wasting of muscle supplied by the nerve. This syndrome involves motor changes of extramedullary lesions beginning with segmental weakness at the lesion site and progressing to dam- age of half of the spinal cord. There is paralysis of motion on one side of the body and loss of sensa- tion on the other side, depending on the site of the lesion involving one side of the spinal cord. Buerger’s disease: Also called thromboangiitis obliter- ans, this condition is a vasculitis that causes inflam- matory lesions of the peripheral blood vessels accompanied by thrombus formation and vasospasm occluding blood vessels. The pathogen- esis of Buerger’s disease is unknown; however, it is generally considered an inflammatory process. Diseases, Pathologies, and Syndromes Defined 387 bulimarexia: An eating disorder in which anorexia nervosa and bulimia nervosa coexist. This is char- acterized by a period of starving to lose weight, alternating with periods of bingeing and purging. The depth of injury is a function of temperature or source of energy and duration of exposure. It may occur in many chronic diseases, such as Alzheimer’s disease; certain malignancies; and advanced pulmonary tuberculosis. Other terms used inter- changeably for cancer are malignant neoplasm, tumor, malignancy, and carcinoma.

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For the age range 45–64 years zenegra 100mg on line, musculo- skeletal pain prevalence was higher in all ethnic groups (about 70 to 90%) than in White subjects discount 100 mg zenegra, with the latter being about 53% for both males and females. When asked whether they had pain in “most joints,” about 6 to 8% of Whites agreed compared to about 30 to 45% in the ethnic minority groups. The authors cautioned that comparable studies need to be done in other geo- graphical locations, because the data do not permit one to readily distin- guish between differences in pain sensitivity or expression, the effects of change of culture and migration, and mental health issues. With respect to the last point, a study (Nelson, Novy, Averill, & Berry, 1996) with a relatively small sample of Black, White, and Hispanic patients in a southern U. McCracken, Matthews, Tang, and Cuba (2001), in one of the few studies of ethnic or racial group differences in the experience of chronic pain, asked 207 White and 57 African American patients seeking treatment at a pain management center about their physical symptoms, depression, dis- ability, health care use, and pain-related anxiety. The two groups did not differ in age, education, or chronicity of their pain complaint. African Ameri- cans rated their pain higher and reported more avoidance of pain and activ- ity, more fearful thinking about pain, and more pain-related anxiety. As well, they were higher on physical symptom complaints and on physical, psycho- social, and overall disability. The authors noted that many factors may ex- plain these findings, including less social support, differences in social cir- cumstances, beliefs about pain, and self-management strategies, and the 170 ROLLMAN possibility that African Americans may not seek or be referred for treat- ment unless they are suffering from high levels of distress. A study by Jordan, Lumley, and Leisen (1998) compared pain control be- liefs, use of cognitive coping strategies, and status of pain, activity level, and emotion among 48 African American and 52 White women with rheuma- toid arthritis, controlling for the potentially confounding influence of in- come, marital status, and education. There were no group differences in pain, but the African American patients were less physically active and more likely to cope with pain by praying and hoping and diverting atten- tion, whereas Whites were more likely to make coping statements and ig- nore the pain. Bill-Harvey, Rippey, Abeles, and Pfeiffer (1989) had earlier noted that 92% of low-income, urban African American arthritis patients used prayer to relieve their pain and discomfort. Cognitive behavior ther- apy and other treatments that encourage the use of increased coping at- tempts and decreased negative thinking can aid African Americans to man- age experimentally induced pain (Gil et al. Waza, Graham, Zyzanski, and Inoue (1999) found that Japanese patients who had been newly diagnosed with depression reported more total symp- toms, particularly physical ones, than patients in the United States. Twenty seven percent of the Japanese patients reported only physical symptoms, whereas only 9% of the patients in the United States presented in this man- ner. A large proportion of the Japanese had pain complaints (generally ab- dominal pain, headache, and neck pain); comparable figures for the Ameri- can patients were about 60 to 80% less. The authors propose that pain at specific body areas may arise because of cultural influences, possibly to avoid the stigma in Japan associated with emotional disorders. For exam- ple, many Japanese expressions use the term hara (abdomen) to verbalize emotion, and digestive-system complaints are the primary reason for out- patient medical visits in that country. Njobvu, Hunt, Pope, and Macfarlane (1999), in a review of pain among in- dividuals from South Asian ethnic minority groups who live in the United Kingdom, observed that they more frequently attend medical clinics and re- port greater musculoskeletal pain. This leads to the question of whether South Asians also suffer greatly from pain in their countries of origin. Hameed and Gibson (1997) provided relevant data in a study of pain com- plaints among Pakistanis living in England and in Pakistan. Those living in England reported more arthritic symptoms and more nonspecific musculo- skeletal pain, particularly among females. There are numerous possible ex- planations including the colder British climate, adjustment to life in a new 6. ETHNOCULTURAL VARIATIONS IN PAIN 171 society, and a greater willingness to report pain among the better educated Pakistanis living in Great Britain. Sabbioni and Eugster (2001) also looked at immigrants, namely, Spanish and Italians living in Switzerland. Earlier studies had found that foreign pa- tients in that country had worse medical outcomes after back injury than Swiss ones, but the migrants often worked in low-paying jobs with in- creased health hazards. There was no difference between groups in pain in- tensity or appraisal, but those immigrants with a high “degree of inclusion” (DI), as measured by type of work permit, age at immigration, and language fluency, were similar to Swiss citizens, and better than immigrants with low DI, with respect to general well-being, functional capacity, and mood. A population-based study of low back pain (LBP) among about 4,000 Bel- gian adults (Skovron, Szpalski, Nordin, Melot, & Cukier, 1994) found that French Belgians (living in the southern region of Wallonia) had a greater likelihood than Flemish Belgians of ever having had LBP. The authors won- dered whether the data are attributable to “a greater willingness among French speakers to share difficulties with the group in contrast with the more individualistic tendencies of the Flemish population,” but they noted that it is also in this region where there are greater economic uncertainties, more heavy industry, and larger companies. REFLECTIONS The many studies reviewed here, and the many included in other reviews (Edwards, Fillingim, & Keefe, 2001; Lasch, 2000; Moore & Brodsgaard, 1999; Rollman, 1998), provide a fascinating view of ethnocultural variations in the experience of pain. The scholarly perspectives, nature of pain, research set- tings, variables investigated, and measures employed vary tremendously.

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The Nineteenth Century—the Rise of Modern Medicine Modern medicine as we know it began during the nineteenth cen- tury order zenegra 100 mg free shipping. The causes of many diseases were beginning to be identified zenegra 100mg sale, and effective treatments were being developed. The nineteenth cen- tury also brought advances in medical research and the birth of modern surgery. One key discovery occurred when a French physician, Jean Corvisart des Marets, found that certain parts of the body have dif- 8 Opportunities in Physician Careers ferent sounds when thumped. Another French physician, René-Théophile Hyacinthe Laënnec, invented the stethoscope in 1819. It is said that he found percussing the chest of one of his patients too difficult, so he rolled up a cylin- der of paper and placed it against the patient’s chest to listen. His publication of successive editions of Traité de l’auscultation médi- ate became the foundation of modern knowledge of diseases of the chest and their diagnosis. In 1846, at Massachusetts General Hospital in Boston, modern surgery was born when William Morton first anesthetized a patient with ether. Unfortunately, patients continued to die on the operat- ing table from infection until chemist Louis Pasteur’s discovery that bacteria caused disease was taken seriously. The Scottish surgeon Joseph Lister understood the importance of Pasteur’s discovery. Lister first tried to kill the bacteria that entered his patients during surgery. Later, he tried to prevent bac- teria from entering wounds by boiling instruments and using antiseptic solutions. Also building on Pasteur’s work, a German physician named Robert Koch experimented with bacteria. He identified the germ that causes tuberculosis and developed the sci- ence of bacteriology. As the causes of disease were becoming more familiar, research into the prevention of disease flourished. The Russian bacteriologist Elie Metchnikoff discovered that certain white blood cells attack bacteria and other particles that enter the blood. In 1890 Karl Landsteiner, a German surgeon, discovered a cure for diphtheria. Landsteiner also isolated the four main blood types and made blood transfusion possible for the first time. That same year, Emil von Behring developed vaccines against tetanus and diphtheria. Physicians: A Historical Perspective 9 The Twentieth Century—Revolutionary Progress The twentieth century saw a tremendous explosion in the under- standing and treatment of disease. Foremost among the develop- ments was an increasingly sophisticated knowledge of how to prevent the onset and spread of illness. The technological advances of this century moved medical practice forward by leaps and bounds as well. In the early 1900s Wilhelm Roentgen began apply- ing the use of x-rays in medicine. This radical new discovery allowed doctors to diagnose problems that previously had been invisible to them, and it advanced surgery as a science. In England, Sir Alexander Fleming discovered by chance that staphylococcus actually dissolved when exposed to Penicillium nota- tum. Fleming extracted an active principle that he called penicillin, which was effective in treating infection. Penicillin was eventually mass-produced in the 1940s and since then has saved millions of lives. With the introduction of the BCG vaccine and streptomycin, tuberculosis, which had been the leading cause of death in the developed world, was largely eradicated there.

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