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The vast majority of the cysts seem to arise from a space between the medial head of the gastrocnemius and the semitendinosis tendon (Figure 4 cheap clomiphene 50mg free shipping menopause jokes. The cysts are clearly benign and have a histologic constitution resembling that of a ganglion cyst buy clomiphene 50mg low price womens health katy. Baker described the lesions in 1887, giving rise to the eponym of Baker’s cyst. Differential diagnosis includes subcutaneous lipomas, popliteal aneurysms, and benign and malignant tumors. All of these should be readily differentiated by radiographic texture, abnormal pulsation, computed tomography (CT) scanning or MRI if the cyst lies in an unusual location. After many years of surgical extirpation, with very frequent recurrences, sanity has begun to prevail, and recognition of the natural history of the disease is now being well appreciated. The vast majority of cysts will either recede in size or disappear within a two- to three-year period after clinical presentation or almost always by puberty. It is to be remembered that ganglions most commonly occur on the dorsal or volar aspects of the wrist and often communicate with the joint. In the absence of clinical symptoms, all cysts should be observed periodically and surgery should be avoided. Operations are generally reserved for those rare children who are suffering from significant pain and whose cysts persist until puberty. Anteroposterior radiograph of the thoracolumbar spine showing Spastic torticollis a thoracolumbar scoliosis. In addition to the far more common congenital muscular torticollis, there is a type of torticollis or “wryneck” that appears in the toddler to adolescent age group that is associated with either inflammatory conditions in the cervical region, traumatic lesions, tumors or neurogenic disorders. The obvious implication is that the source of the “wryneck” is secondary to some other medical condition apart from the sternocleidomastoid muscle. One of the more common reasons for a spastic torticollis is atlantoaxial rotary From toddler to adolescence 72 “subluxation. Typically the children “splint” and resist any attempts to rotate the head or the neck. The term rotary displacement is probably more appropriate inasmuch as it is uncommon to document any true radiographic subluxation of the atlantoaxial joint. Fortunately the condition resolves almost invariably and spontaneously, with or without treatment (physical therapy, traction, heat). Spastic torticollis is also occasionally seen following upper respiratory infections, in association with cervical adenitis. Presumably the inflamed lymph nodes irritate the sternocleidomastoid and the anterior cervical “strap” muscles, producing the torticollis. Diagnosis is established by identifying the primary infection and treatment by the primary care physician generally results in resolution of the torticollis. Spinal cord tumors and cerebellar tumors occasionally can produce a spastic torticollis. An adequate neurologic evaluation is mandatory and a part of evaluating all acquired cases of torticollis. Symptomatic treatment is generally used for spastic torticollis in the form of heat, massage, and intermittent cervical traction, providing there is no evidence of true cervical vertebral instability. Resolution is generally abrupt in inflammatory and atlantoaxial rotary displacements. Subluxation of the radialhead “Pulled elbow” is most commonly seen in children between one and five years of age. It occurs following an injury sustained in which the child’s forearm or hand is being held and the child attempts to fall away, or is lifted from 73 Muscular dystrophies the ground by the hands. The children tend to carry the forearm in a “lame” position of forearm pronation, and elbow flexion supported by the other hand (Figure 4. Supination of the forearm or pressure over the radial head increases the discomfort. True subluxation or dislocation of the radial head from its position against the capitellum has never been demonstrated radiographically or pathologically. The condition occurs when longitudinal traction is applied to the forearm with the arm extended and the forearm pronated. It is believed that a portion of the annular ligament becomes interposed between Figure 4.

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The back discount 100 mg clomiphene free shipping menopause at 70, See “hematuria algorithm” (Figure 27-1) for evalua- flank generic clomiphene 25 mg otc breast cancer 8 years later, abdomen and genitalia are examined paying tion and treatment. PROTEINURIA DIFFERENTIAL DIAGNOSIS AND TREATMENT CLINICAL FEATURES Differential diagnosis includes urinary tract infection, nephrolithiasis, urethritis, prostatitis, glomerulone- Proteinuria is defined as more than 150 mg of protein phritis, bladder cancer, and medications. Normal urine protein is Grossly bloody urine should always be dipstick tested composed of 30% albumin, 30% serum globulins, and for blood and red blood cells confirmed by microscopy. Post-exercise proteinuria is rela- When myoglobin or hemoglobin is present, urine will tively common and has been described for well over test positive for blood but red blood cells are absent on 120 years. Medications, dyes, and food and noncontact and is associated with strenuous activity, 160 SECTION 3 MEDICAL PROBLEMS IN THE ATHLETE FIG. A family history of heredi- tary nephritis or polycystic kidney disease is important. CLINICAL FEATURES Ameticulous physical examination should be com- pleted. Vital signs, especially blood pressure, should Acute renal failure in athletes is typically caused by always be obtained. The back, flank, abdomen, skin, complications associated with strenuous exercise such and genitalia are examined in routine fashion. Increased magnitude and duration of dehydration can lead to acute tubular necrosis. Hemolysis due to hyperpyrexia contributes to acute tubular necrosis DIFFERENTIAL DIAGNOSIS AND TREATMENT (ATN) and renal failure. CHAPTER 27 GENITOURINARY 161 The athlete in acute renal failure often presents with Athletes with severe renal injuries (Class IV and V) nonspecific complaints, such as malaise, weakness, often present in hypovolemic shock. Aggressive loss of appetite, nausea, anuria or oliguria, and symp- intravascular volume replacement, transfusion, and toms of dehydration. Obstructive uropathy is bed rest, and repeat urinalysis to assess for resolution rarely a source of renal failure. The athlete is restricted from contact Serum laboratory tests include a complete blood sports and a repeat IVP is obtained at 3 months. With this data, a fractional URETERS excretion of sodium (FENa) can be calculated to differ- entiate between prerenal azotemia and ATN as the Ureteral injury is associated with severe trauma, such as cause of kidney failure. Hematuria is present in 90% of Identification of the endogenous nephrotoxin such as ureteral trauma. The diagnosis is best established uti- myoglobin in rhabdomyolysis or the exogenous lizing IVP and retrograde pyelogram. Indications for dialysis include the BLADDER need for ultrafiltration of a volume-overloaded state or the need for solute clearance. Patients with bladder contusion present with a history of trauma, GENITOURINARY TRAUMA suprapubic pain, guarding, hematuria, and possibly dysuria. RENAL Bladder rupture may be intra- or extra-peritoneal and is usually associated with pelvic fracture. A blow to the cling and presents with abrupt onset of urinary fre- flank or abdomen produces a coup or countercoup quency, diminished urinary stream, nocturia, and mechanism of injury. Bladder contu- Kidney injuries are divided into 5 classes based on sions are treated with catheter drainage for a few days. Class II: Cortical laceration Class III: Caliceal laceration Class IV: Complete renal fracture—rare sports injury GENITALIA Class V: Vascular pedicle injury—again, rare in sports Flank pain or gross hematuria after blunt trauma in an Genital trauma may occur in any sport, though it’s athlete requires consideration of possible renal injury. Gross or microscopic hematuria is present Testicular injuries result from direct trauma and in greater than 95% of renal trauma. Other urologic emergency requiring surgical management if sports to include in this category are basketball, the testis is to be salvaged. The penis majority of sports-related eye injuries (Napier et al, may be injured in straddle-type injuries or by direct 1996). Irritation of the pudendal nerve in bicycle racers can cause priapism or ischemic neuropathy of the penis. Symptoms usually resolve once the race PREPARTICIPATION PHYSICAL is over.

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We have had little – and not particularly positive – ex- perience of the bump resection generic 100mg clomiphene visa menstruation reduce bleeding. Since the joint cartilage inevitably has to be resected along with the bump 100 mg clomiphene overnight delivery breast cancer football socks, it is not surprising that the condition of the joint is frequently not improved by this procedure. In arthrodiastasis an external fixator is used between the pelvis and the femur. Distrac- tion is applied and the hinge of the distractor is periodi- cally opened to allow movement of the joint. The intertrochanteric valgus osteotomy on the other hand is often an effective procedure (⊡ Fig. In a recent multicentric investigation among the members of the »European Pediatric Orthopedic Society« (EPOS) we tried to find out what principles of treatment are used in Europe. A questionnaire was sent to all 297 members of the society describing four cases of Legg-Calvé-Perthes disease with 2 x-rays each and a short description of the clinical situation. Two of the patients were younger and two were older than 6 years of age. In both age groups there was one patient with a good range of motion and an x-ray classified Herring A or B, while the other patient had a poor range of motion and an x- b ray classified as Herring C. The members were asked to choose from various treatment options or to describe ⊡ Fig. Treatment in the defect stage with intertrochanteric val- any other therapy that they would advise in the clinical gization osteotomy for severe hinge-abduction. There was a consensus, that no »bump« has been rotated out of the weight-bearing zone 214 3. Our therapeutic strategy for Legg-Calvé-Perthes disease Under 5 years If mobility is restricted: physical therapy Check ultrasound scan every 3 months X-rays (AP and axial) every 6 months up to 2 years after the diagnosis, and then annually 5 to 7 years If mobility is restricted: physical therapy If mobility is very restricted: botulinum toxin injection in the adductors 3 Check ultrasound scan every 3 months X-rays (AP and axial) every 6 months up to 2 years after the diagnosis, and then annually If decentering is present: operation Generally intertrochanteric osteotomy (precondition: epiphyseal plate not too steep, no major leg shortening and only slight restriction of abduction) If the preconditions for an intertrochanteric osteotomy are not satisfied, then pelvic osteotomy according to Salter Over 7 years Triple osteotomy of the pelvis (if mobility is greatly restricted poss. Cannon SR, Pozo JL, Catterall A (1989) Elevated growth velocity in more on the personal experience of the surgeon rather children with Perthes’ disease. Coates CJ, Paterson JM, Woods KR, Catterall A, Fixsen JA (1990) Femo- Our therapeutic strategy for Legg-Calvé-Perthes ral osteotomy in Perthes’ disease. Conway JJ (1993) A scintigraphic classification of Legg-Calve-Perthes Our therapeutic strategy for Legg-Calvé-Perthes disease is disease. Cooperman DR, Stulberg SD (1986) Ambulatory containment treat- ment in Perthes’ disease. Crutcher JP, Staheli LT (1992) Combined osteotomy as a salvage pro- crutches only for very severe pain, no total ban on cedure for severe Legg-Calve-Perthes disease. Farsetti P, Tudisco C, Caterini R, Potenza V, Ippolito E (1995) The Her- 1. Adekile A, Gupta R, Yacoub F, Sinan T, Al-Bloushi M, Haider M (2001) ring lateral pillar classification for prognosis in Perthes disease. J Bone Avascular necrosis of the hip in children with sickle cell disease and Joint Surg (Br) 77: 739–42 high Hb F: magnetic resonance imaging findings and influence of 17. Fulford GE, Lunn PG, Macnicol MF (1993) A prospective study of non- alpha-thalassemia trait. Acta Haematol 105: p27–31 operative and operative management for Perthes’ disease. Aigner N, Petje G, Schneider W, Krasny C, Grill F, Landsiedl F (2002) Ju- Orthop 13: 281–5 venile bone-marrow oedema of the acetabulum treated by iloprost. Gallistl S, Reitinger T, Linhart W, Muntean W (1999) The role of in- J Bone Joint Surg Br 84: 1050–2 herited thrombotic disorders in the etiology of Legg-Calve-Perthes 3. Barwood S, Baillieu C, Boyd R, Brereton K, Low J, Nattrass G, Graham disease in the very young child. J Pediatr Orthop B 15: 16-22 H (2000) Analgesic effects of botulinum toxin A: a randomized, pla- 20. Ghanem I, Khalife R, Haddad F, Kharrat K, Dagher F (2005) Recurrent cebo-controlled clinical trial. Dev Med Child Neurol 42: 116–21 Legg-Calve-Perthes disease revisited: fake or reality? Bassett GS, Apel DM, Wintersteen VG, Tolo VT (1991) Measurement of B 14: 422-5 femoral head microcirculation by Laser Doppler Flowmetry.

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If you are willing to address their comments adequately in a revised version of your paper cheap clomiphene 100 mg mastercard women's health center at presbyterian dallas, we should be happy to accept it for publication 50mg clomiphene sale menopause 10. It is difficult to complete an editorial evaluation at this point in time. Please respond to each reviewer’s comments point by point and resubmit your article to us. As you can see from their enclosed comment, they have a number of suggestions, which they feel should be addressed before we are able to accept the manuscript for publication. If you are able to respond to these comments in an amended manuscript we shall then review the manuscript before final acceptance. If we have not heard from you in 3 months time, we will assume that you do not want to amend your manuscript and your file will be closed. Three international reviewers have submitted comments about your manuscript. Together with the assistant chief editor, we generally agree with their remarks. If you would like to thoroughly revise the manuscript according to the combined suggestions, we should be happy to consider it again. Please submit the amended manuscript and three copies in addition to a copy of the original marked with the changes you have made within 3 months. Remember that you can withdraw from a journal at any time but the withdrawal has to be formally accepted at editorial level before you can submit the paper to another journal. Deciding to withdraw and then submit to another journal will bring another set of reviewers’ comments, albeit different ones, and will almost certainly delay the publication of your paper. If the paper is in a very specialised field, it may well find its way back to one of the original reviewers who will be less than impressed if you have not taken their original comments on board. BF Skinner When you receive the reviewers’ comments, the extent of them may leave you feeling devastated. This is a normal response when unknown peers widely criticise many aspects of your work. All you need to do is deconstruct each of the messages into individual items that you can respond to. In doing this, you will find that many comments are more easily responded to than at first thought. It is probably best to try and make the majority of the changes requested, and to try carefully to negotiate the more radical suggestions as needed. At the end of the line, editors take the review process very seriously so no comments from the reviewers should be lightly dismissed. Sending back a paper with minimal changes implies either disdain or arrogance for the review process and will not impress the journal editor. Your replies to the reviewers’ comments should make your responses very clear. This is the time to get the editorial panel on your side by simplifying the work they have to do in assessing your responses. Basically, you must take a positive attitude and put a lot of thought into your responses. A good way to respond is to use a table in which you list each of the reviewers’ comments, your responses, and the amended text as shown in Table 5. You don’t have to fully accept all suggestions but, if you don’t, you need to give reasons that will convince the editor that your opinion is reasonable. In doing this, it is best to be pragmatic and not to be dismissive of the reviewers’ work. Tabulating the responses makes it very clear what changes you have made and where you have made them. For comment 1, the reviewer’s suggestion has been met half way by shortening the section considerably but still leaving some information in the paper. For comments 2, 5, 6, 8, and 9, 127 Scientific Writing the reviewer’s suggestions have been accommodated entirely. For comment 3, the response is to politely point out that the explanation of the sampling processes was unclear in the original paper and has been amended. In response to the reviewer’s comment 4, it would be tempting to point out that Bland and Altman do not describe a “coefficient of repeatability” and that the reviewer might like to get his facts right! It is better to be certain that you have used the correct statistic and to just note what you have done, as in our reply.

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