By Z. Kor-Shach. University of Findlay.

John P Kugler generic lamictal 50mg with visa, MD buy lamictal 100mg on-line, MPH W hile there is a definite increased risk for certain sus- Ralph P Oriscello buy 50mg lamictal overnight delivery, MD, FACC ceptible individuals, particularly middle-aged persons with coronary artery disease (CAD) and a sedentary lifestyle, there is abundant evidence (Maron, 2000) of net cardiovascular benefits from consistent exercise as a INTRODUCTION primary-prevention recommendation for coronary dis- ease in asymptomatic middle-aged and older persons. Regular physical activity promotes THE ATHLETIC HEART SYNDROME cardiovascular fitness and lowers the risk of disease. These changes are nonpathologic and represent until the adverse event occurs. Of note, detraining for 2–3 months can result in a reversal of CARDIOVASCULAR BENEFITS athletic heart syndrome changes, which is not seen in OF EXERCISE pathologic conditions. Colditz, 1990) have clearly identified physical inac- For endurance-trained athletes, the heart has to tivity and a sedentary lifestyle as significant risk fac- adapt to principally a chronic volume overload that tors for the development and progression of coronary results in an increase in both left ventricular end- heart disease. Moreover, studies (Pate et al, 1995; diastolic diameter and left ventricular wall thickness. Electrocardiograms of the General Population and Athletes The strength-trained athlete adapts by developing a GENERAL concentric hypertrophy with an increase in absolute ARRHYTHMIA POPULATION (%) ATHLETES (%) and relative wall thickness without significant Sinus bradycardia 23. An S3 may be noted in endurance-trained athletes secondary to the increased SUDDEN DEATH IN EXERCISE rate of left ventricular filling associated with the rela- tive left ventricular dilatation (Zeppilli, 1988). Functional mur- has clearly shown, there is a “paradox of exercise” murs may be noted in 30–50% of athletes on careful that requires a clinical assessment of risk prior to the examination (Huston, Puffer, and Rodney, 1985). Estimates from various studies (Siscovick et al, 1984; ELECTROCARDIOGRAPHIC CHANGES Ragosta et al, 1984; Thompson et al, 1982; Maron, Poliac, and Roberts, 1996; Van et al, 1995; Maron, Several minor electrocardiogaphic variations have Gohman, and Aeppli, 1998) range from 1:15,000 jog- been commonly noted in highly trained athletes and gers per year (Siscovick et al, 1984; Thompson et al, are considered to be consistent with the athlete’s heart 1982) to 1:50,000 marathon participants (Maron, syndrome (Huston, Puffer, and Rodney, 1985; Oakley Poliac, and Roberts, 1996). In a recent Italian study The specific etiologies contributing to sudden cardiac (Pelliccia et al, 2000), 1005 athletes were consecu- death are most closely related to age. This primarily stems study found that 40% of the athletes had abnormal from the observation that for sudden deaths over age 35, EKGs, not including the minor alterations associated over 75% are associated with coronary artery disease. Of The high prevalence of atherosclerosis in this age group these athletes, 36% had distinctly abnormal patterns. In European studies (Tabib et al, 1999; Firoozi et al, 2002; Priori et al, 2002), arrhythmogenic right ven- TABLE 25-1 Common ECG Findings in Athletic tricular cardiomyopathy (ARVC) is more commonly Heart Syndrome recognized as an etiology than it is in the United Sinus bradycardia Sinus arrhythmia States. Other less common etiologies include aortic First-degree AV block Wenckebach AV block Incomplete RBBB Notched P waves rupture from Marfan’s syndrome, genetic conductive RVH by voltage criteria LVH by voltage criteria system abnormalities, idiopathic concentric left ven- Repolarization changes QTc interval at upper limit tricular hypertrophy, substance abuse (cocaine or Tall, peaked and inverted t waves steroids), aortic stenosis, mitral valve prolapse, CHAPTER 25 CARDIOVASCULAR CONSIDERATIONS 143 sickle cell trait, and blunt chest trauma (commotio TABLE 25-4 Features of Marfan Syndrome cordis). Joint laxity It is recommended that a complete personal and family Cardiovascular history and physical examination be done for all ath- Systolic murmur (mitral valve prolapse) letes. It should focus on identifying those cardiovascu- Evidence of easing bruising lar conditions known to cause sudden death. It should Diastolic murmur (aortic regurgitation) be done every 2 years with an interim history between Ocular examinations. The 26th Bethesda Conference specifies Myopia participation guidelines for different conditions Retinal detachment Lens subluxation (Maron and Mitchell, 1994). Cardiac auscultation should be performed in hypertension, hyperlipidemia, smoking, or on the pres- the supine and standing positions and murmurs ence of HCM, ARVC, Marfan’s syndrome, prolonged should be assessed with Valsava and position QT syndrome, or significant arrhythmias. The murmur of aortic stenosis inten- Contraindications to Vigorous Exercise sifies with squatting, and decreases with Valsalva.

A warmed enema of a water-soluble trusted 25mg lamictal, iodined-based ionic contrast agent is the examination of choice to assist in diag- nosis and promote the passage of the meconium buy lamictal 200mg fast delivery. Congenital megacolon (Hirschprung’s disease) The congenital absence of ganglionic nerve cells in the wall of the colon results in a complete or partial functional obstruction and dilation of the large bowel as a consequence of peristaltic failure generic lamictal 100 mg mastercard. Congenital megacolon accounts for 10–20% of all neonatal intestinal obstructions and may be associated with perforation (5% of cases). The plain abdominal radiograph may demonstrate a distal colonic obstruction with extremely dilated bowel proximal to it. Necrotising enterocolitis Necrotising enterocolitis (NEC) is a progressive inflammatory disease of the bowel commonly associated with prematurity (85% of cases developing in 13 neonates of less than 37 weeks gestational age ). However, infection, maternal substance abuse and umbilical cannulation are all associated with an increased risk of NEC9. Clinical symptoms are initially non-specific but as the disease progresses abdominal distension, bilious vomiting, bloody stools, intestinal obstruction and perforation of the bowel wall may be noted. Abdominal radiographs in the initial stages of the disease are non-specific demonstrating minimal gastric or bowel distension. As the condition progresses, greater distension of the bowel, air in the bowel wall (pneumatosis intestinalis) and pneumoperitoneum as a result of bowel perfora- tion (30% of cases) may be seen (Figs 6. Plain film radiography of the abdomen may be requested in order to monitor the progress of the Fig. However, ultrasound may also have a role to play in the assessment of suspected pneumatosis intestinalis. Contrast studies are not indicated during the acute phase but a contrast enema may be undertaken at follow-up to demon- strate any resultant bowel strictures13. Abdominal mass An abdominal mass is identified in approximately 1 in every 1000 live births14 and, during the neonatal period, these are most frequently associated with renal tract abnormalities (see Chapter 5). In all circumstances, ultrasound is the imaging modality of choice for primary investigations. Jaundice Neonatal jaundice may result from a variety of physiological and metabolic causes, most of which can be successfully treated medically without the need for imaging. Prolonged neonatal jaundice (>7–10 days) is a common indication for urgent ultrasound imaging of the neonatal liver, primarily to exclude biliary atresia9 (partial or complete congenital interruption of the common bile duct12). Catheters, lines and tubes Many neonatal radiographic examinations are undertaken to assess the position of lines and catheters prior to their medical use and it is important that radiog- raphers are able to identify incorrectly positioned catheters and bring these find- ings to the attention of their radiological and medical colleagues. Endotracheal tube Endotracheal intubation is necessary for mechanical ventilation, and accurate positioning of the endotracheal tube within the trachea is essential if effective ventilation is to be achieved and respiratory obstruction avoided. The distal tip of the tube should be positioned at the level of the second thoracic vertebra, approximately 1 – 2cm above the carina2. It is important, when undertaking plain film radiography to assess the position of the endotracheal tube, that the baby’s head is in its natural position (i.

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Sometimes if the blood Infection flow is low lamictal 100 mg for sale, then compression of the probe on the skin or of the distal limb may be needed to confirm the In bone infection a periosteal reaction may be seen vascularity purchase 200 mg lamictal with visa. Colour Doppler will show the presence of in the early phases of osteomyelitis when little is large feeding vessels and at what depth the lesion lies cheap lamictal 25 mg online. However, the opposite is Superficial vascular lesions will give a bluish hue to not true; early infection does not always produce a the skin. There may be areas of calcification due to demonstrable periosteal elevation. An abscess can phleboliths and these will be detected on US as highly identified as a fluid collection. Although the lesion reflective areas with a little acoustic shadowing may contain “solid” echoes, it is well circumscribed behind. A sinus may be seen as a low most common, US is also the easiest imaging to echo track between areas of abnormal tissue. There are approximately 100 benign lesions patient has an MRI examination as the patient is to 1 malignant lesion. The most common soft tissue placed in the supine position and the lump disap- sarcoma is the rhabdomyosarcoma, and second is pears. They are derived from author has even had patients whose lumps are only primitive mesenchymal tissue which probably has visible on standing after a run just prior to the US an association with skeletal muscle embryogenesis. There is great relief to both the Synovial sarcoma, despite its name, is unrelated to family and patient when a definite diagnosis can the synovium of joints and can be found anywhere in be made, and for this problem only US will give the body, but most commonly in the lower extremi- the answer! The bone lesion that can invasion but will not be as useful as MR in pro- cause soft tissue swelling is the soft tissue extension viding local staging which is essential for surgical of a Ewing’s sarcoma. US is used in the assessment of the carti- peripheral nerve sheath tumours are rare. When dence of abnormal vascularity alone cannot deter- the cartilage cap is greater than 3 cm in a child then mine whether a lesion is benign or malignant. They there is an increased suspicion of malignant trans- are solid lesions and therefore have a mixed echo formation into a chondrosarcoma. They may contain calcification and then US can be used to biopsy such a lesion, but once the they have “bright” echoes within them. This is not only possible also have “cystic” areas which are due to necrosis. Soft Tissue Tumours in Children 81 Liposarcoma is a rare lesion in childhood.

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Individuals are considered more likely to Perspectives on Pain and Depression 15 engage in actions they believe are both within their capabilities and will result in a positive outcome cheap lamictal 200mg with amex. Self-efficacy beliefs mediate the relationship between pain intensity and disability in different groups of patients with chronic pain [Arnstein et al purchase lamictal 25mg amex. The lack of belief in one’s own ability to manage pain 50mg lamictal overnight delivery, cope and function despite persistent pain is a significant predictor of disability and secondary depression in patients with chronic pain. Patients with a variety of chronic pain syndromes who score higher on measures of self-efficacy report lower levels of pain, higher pain thresholds, increased exercise performance and more positive coping efforts [Asghari and Nicholas, 2001; Barry et al. More sophisticated models of pain and depression add the component of illness behavior (functional disability), which functions both as a response of the vulnerable individual to a significant stressor but then later as a stressor itself [Revenson and Felton, 1989]. The severity of depression has been found to be unaffected by pain intensity when pain-related disability is controlled [Von Korff et al. If pain causes disability such as loss of independence or mobility that decreases an individual’s participation in activities, the risk of depression is significantly increased [Williamson and Schulz, 1992]. In a clinical trial of patients with chronic low back pain, the association between pain and depression was attributable to disability and illness attitudes [Dickens et al. The fear-avoidance model and expectancy model of fear provide explanations for the initiation and maintenance of chronic pain disability with avoidance of specific activities [Greenberg and Burns, 2003; Lethem et al. Fear of pain, movement, reinjury, and other negative consequences that result in the avoidance of activities promote the transition to and sustaining of chronic pain and its associated disabilities such as muscular reactivity, deconditioning, and guarded movement [Asmundson et al. Patients with chronic low back pain who restricted their activities developed physiological changes (muscle atrophy, osteoporosis, weight gain) and functional deterioration attributed to deconditioning [Verbunt et al. This process is reinforced by negative cognitions such as low self-efficacy, catastrophic inter- pretations, and increased expectations of failure regarding attempts to engage in rehabilitation. Fear-avoidance beliefs have been found to be one of the most significant predictors of failure to return to work in patients with chronic low back pain [Waddell et al. Operant conditioning reinforces disability if the avoid- ance provides any short-term benefits such as reducing anticipatory anxiety or relieving the patient of unwanted responsibilities. In a study of patients with chronic low back pain, improvements in disability following physical therapy Clark/Treisman 16 were associated with decreases in pain, psychological distress, and fear-avoidance beliefs but not specific physical deficits [Mannion et al. Decreasing work-specific fears was a more important outcome than addressing general fears of physical activity in predicting improved physical capability for work among patients participating in an interdisciplinary treatment program [Vowles and Gross, 2003]. Patients may require disability status in order to obtain resources needed for rehabilitation and recovery from illness. Unfortunately, improved functional status becomes linked to withdrawal of financial resources. Suddenly, the patients in the midst of rehabilitation find themselves unable to pay for medications or other necessary therapies because their func- tional status has improved but not completely returned to premorbid levels. Disability resources now reward illness behaviors and undermine recovery. The insurance industry has further complicated this problem by excluding preexisting conditions so that patients who choose to return to work risk losing their disability coverage for the future.

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