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Subsequently depakote 500 mg for sale treatment xyy, questioning TAKING THE EXAM oneself about the material and periodically reviewing are critical cheap 250mg depakote medications equivalent to asmanex inhaler. We forget Reviewing of important information the day before the the most in the first 24 hours after learning, and it is exam can be beneficial, but keep the sessions to an hour during this period that review is most helpful. Eat regular, moderate-sized may be related to anxiety, distraction, emotional distur- meals. Intellectual inter- exercise regularly, continue it the day before the exam. It is probably best not to study at all in the last can be minimized by reflecting on what has just been hours before the exam. You may want to avoid caffeine, learned, and by synthesizing and organizing the material even if you use it regularly, as the combination of before moving on to other topics. Another strategy is to examination anxiety and caffeine may produce over- follow a learning session with sleep or nonintellectual stimulation. A lack of Arrive at the examination site early enough that you attention or effort during the learning process is very are not rushed or stressed. There must be concentration without tions on the exam and calculate the amount of time you distraction during the learning process, and a conscious can spend per question. Computer-based exams usually provide a brief practice 1 TEST PREPARATION AND PLANNING 5 exam that can be used prior to the start of the actual 2. College Learning and Study your own answer or answers to the questions before Skills. This is particularly helpful for K-type questions, but will also help narrow the field for A-type questions. Some questions ask for the ONLINE RESOURCES best answer among responses that may have more than one correct answer. University of New Mexico Center for Academic Program For examinees who are prone to test anxiety, it may Support be helpful to read through but not answer difficult ques- http://www. This technique provides momentum and confidence to com- University of South Australia Learning Connection plete the exam initially. Rework difficult questions and look Dartmouth Academic Skills Center for errors on easy questions, such as selection of the http://www. Section II BASIC PHYSIOLOGY peptides and/or neurotransmitters and injury products 2 NOCICEPTIVE PAIN like prostaglandins, as well as infiltrating immune Linda S. Sorkin, PhD cells and blood products (eg, bradykinin) escaping from the vasculature, make important contributions to inflammation and to the pain resulting from the INTRODUCTION injury. If thermal thresh- afferent fiber that goes from the skin to the spinal old is reduced such that body temperature initiates cord, the spinal cord projection neuron (usually neural activity, this looks like spontaneous pain. This provides the rationale for intraar- ticular opiates during knee surgery and for local patch TISSUE INJURY application of some antihyperalgesic agents. AFFERENT PAIN FIBERS Action potentials are generated in nerve fibers that respond exclusively to potentially tissue-damaging Most fibers that transmit acute nociceptive pain are stimuli—mechanical, thermal, or chemical. Not all Aδ and C fibers transmit pain information; While some are specific to one modality (eg, cold or many code for innocuous temperature, itch, and a particular chemical like histamine) the majority are touch. Many of injury or peptides released from collaterals of acti- these are thought to play a prominent role in arthritis vated nociceptive nerve terminals (eg, calcitonin pain and other diseases associated with tissue damage gene-related peptide [CGRP] and substance P) induce or inflammation. The viscera contain a particularly increased vascular permeability and escape of plasma large proportion of silent nociceptors. This causes edema at the Parallel experiments comparing electrophysiological injury site and the flare around it. Primary afferent data in single C nociceptive fibers with human 7 Copyright © 2005 by The McGraw-Hill Companies, Inc. This suggests that nociceptive pri- mechanoreceptors or thermoreceptors or they may mary afferent fiber activity mediates pain and that exhibit convergence; that is, they receive input from inhibition of this activity diminishes pain. If these convergent cells vated by capsaicin and contain a variety of neuropep- fire significantly more action potentials in response to tides, while others are capsaicin insensitive. All have noxious stimuli, they are called wide dynamic range monosynaptic terminations in laminae I and II of the (WDR) cells. C fibers have polysy- Convergence of input from the outer body surface naptic connections with neurons in lamina V as well (skin) and from viscera onto individual spinal neurons as with neurons in deeper dorsal horn. When activity is initiated in viscera, pain tive afferents from viscera have monosynaptic input is referred to the portion of the body surface that to lamina X around the central canal as well as “shares” those neurons.

Follow-up examination of the first 18 patients con- firmed that all patients were pain-free after reduction Our therapeutic strategy for spondylolysis and spondylolisthesis The therapeutic strategy for spondylolysis and spondylo- listhesis in our hospital is shown in ⊡ Table 3 order 250 mg depakote otc medicine hat lodge. Albanese M generic 250 mg depakote visa medications list template, Pizzutillo PD (1982) Family study of spondylolysis and spondylolisthesis. Beutler W, Fredrickson B, Murtland A, Sweeney C, Grant W, Baker D (2003) The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Capasso G, Maffulli N, Testa V (1992) Inter- and intratester reli- ability of radiographic measurements of spondylolisthesis. Danielson BI, Frennered AK, Irstam LK (1991) Radiologic progression of isthmic lumbar spondylolisthesis in young patients. Dick WT, Schnebel B (1988) Severe spondylolisthesis: Reduction and internal fixation. Elke R, Dick W (1996) The internal fixator for reduction and stabili- zation of grade III-IV spondylolisthesis and the significance of the sagittal profile of the spine. Grobler LJ, Robertson PA, Novotny JE, Pope MH (1993) Etiology of spondylolisthesis. Schematic presentation of the shift in the center of gravity joint morphology. Spine 18: 80–91 in severe spondylolisthesis (grade IV) with kyphosis between L5 and 7. Hefti F, Brunazzi M, Morscher E (1994) Spontanverlauf bei Spondy- the sacrum (dark). Therapeutic strategy for spondylolysis and spondylolisthesis Growth age Spondylolysis with or without spondylolisthesis grade 0–II, No treatment no symptoms Spondylolysis with or without spondylolisthesis grade 0–II, Physiotherapy, avoid lordosing exercises; if persists for more typical pain than 6 months, poss. Hennrikus WL, Rosenthal RK, Kasser JR (1993) Incidence of spon- dylolisthesis in ambulatory cerebral palsy patients. Ivanic G, Pink T, Achatz W, Ward J, Homann N, May M (2003) Direct poses problems for the lung. Konermann W, Sell S (1992) Die Wirbelsäule – Eine Problemzone im Kunstturnhochleistungssport. Eine retrospektive Analyse von Congenital deformity of the axial skeleton at one or 24 ehemaligen Kunstturnerinnen des Deutschen A-Kaders. Sport- more levels leading to axial deviations in the sagittal verletz Sportschaden 6: 156–60 (congenital kyphoses) and frontal (congenital scolioses) 12. Konz RJ, Goel VK, Grobler LJ, Grosland NM, Spratt KF, Scifert JL, planes, possibly combined with rotation. Sairyo K (2001) The pathomechanism of spondylolytic spondy- lolisthesis in immature primate lumbar spines in vitro and finite Etiology element assessments. Lenke L, Bridwell K (2003) Evaluation and surgical treatment of Most congenital malformations of the spine are acquired high-grade isthmic dysplastic spondylolisthesis. A hereditary or familial factor is in- 52: 525–32 volved in only around 1% of cases [7, 15]. McGregor AH, Cattermole HR, Hughes SP (2001) Global spinal mo- forms are usually associated with multiple anomalies. Spine However, an increased incidence of idiopathic scoliosis 26: 282–6 has been observed in families of patients with congenital 15. Morscher E, Gerber B, Fasel J (1984) Surgical treatment of spondy- bodies (excluding meningomyelocele), a risk of 5%– lolisthesis by bone grafting and direct stabilization of spondyloly- sis by means of a hook screw. Niethard F, Pfeil J, Weber M (1997) Ätiologie und Pathogenese der is spondylothoracic dysplasia described by Jarcho and spondylolytischen Spondylolisthese. Orthopäde 26: 750–4 Levin with multiple bilateral segmentation defects, 18. Nyska M, Constantini N, Cale-Benzoor M, Back Z, Kahn G, Mann G fused ribs and segmental aplasia (⊡ Fig. This condi- (2000) Spondylolysis as a cause of low back pain in swimmers. Omey M, Micheli L, Gerbino P (2000) Idiopathic scoliosis and spon- multiple deformities likewise occur in Vacterl syndrome: dylolysis in the female athlete. Clin Orthop in addition to vertebral anomalies, this syndrome is 372: 74–84 characterized by anal atresia, tracheoesophageal fistulas, 20. Sakamaki T, Katoh S, Sairyo K (2002) Normal and spondylolytic esophageal atresia, renal malformations and dysplasia of pediatric spine movements with reference to instantaneous axis the radius. Sales de Gauzy J, Vadier F, Cahuzac J (2000) Repair of lumbar spondylolysis using Morscher material: 14 children followed for 1–5 years.

Exposure should be made with the patient’s mouth closed on gentle inspiration buy depakote 500 mg with mastercard symptoms zyrtec overdose. The primary beam should be centred over the middle of the mandibular ramus and to the centre of the film buy 500mg depakote with visa treatment 10. Note: Careful collimation should be undertaken to avoid irradiation of the thyroid gland and the lens of the eyes. Radiographic assessment criteria of post-nasal space The mandibular rami should be superimposed and the nasopharynx clearly out- lined with air. Note the child’s arms are positioned around the erect cassette holder to assist in immobilisation. Age Focal Kilovoltage mAs FFDa Relative screen/ Grid AECb (years) spot (kV) (cm) film speed <1 Fine 60 2 150 400–800 No No 1–4 Broad 75 2 150 400–800 No No 4–10 Broad 75 4 150 400–800 Yes No 10+ Broad 80–120 AEC 150–180 400–800 Yes/No Yes (dependent (dependent on size) on size) aFocus-to-film distance. Exposure factors and radiation protection The European Guidelines14 recommend a fast film screen combination, 400–800 speed class, for use in paediatric chest radiography combined with an exposure time of less than 10ms to reduce the risk of recorded movement unsharpness. The use of automatic exposure control (AEC) is not recommended for infants and small children due to the relatively large size of the chamber compared to the area of interest and the difficulty of positioning the chamber to an appropri- ate anatomical area. A relatively high kV should be used to reduce the radiation dose (Table 4. If difficulties in using high kV are encountered as a result of being unable to set sufficiently low mAs values then increasing the filtration within the tube is advocated. This will reduce tube output per mAs thereby allowing tube potential to be increased for infant examinations15. Additional filtration will also reduce the amount of low energy photons within the radiation beam and therefore assist in the reduction of patient dose. The use of an anti-scatter grid or Bucky is not appropriate for chest radiogra- phy on small children. These examples assume that additional filtration has been added to the x-ray tube as recommended by the European Guidelines14. Summary Although frequently undertaken, many radiographers are still uncomfortable performing paediatric chest examinations and it is hoped that, by providing a description of suitable techniques, including associated radiographic assessment criteria and common chest pathologies, the radiographer will be able to improve 62 Paediatric Radiography not only their technical ability, but also their understanding of paediatric pul- monary diseases. However, the use of ionising radiation for imaging the paediatric abdomen is increasingly being questioned and radiographers must ensure that plain film radiography is justified as there are an increasing number of clinical presentations for which plain film radiography is no longer appropriate as the first-line imaging investigation. Structural and functional anatomy The abdomen is defined by the diaphragm superiorly and the pelvic inlet infe- riorly. Most abdominal radiography, however, relates to the gastrointestinal and genitourinary tracts and these anatomical systems extend beyond these boundaries. Gastrointestinal system The gastrointestinal system extends from the mouth superiorly to the anal opening and includes the buccal cavity, the pharynx, the oesophagus, the stomach, and the small and large bowel. At birth, the tongue lies wholly within the mouth and during the first 4 or 5 years of life, the posterior part descends with the larynx to form part of the ante- rior wall of the pharynx. Before the tongue and larynx descend, their high posi- tion allows the child to breathe freely while fluid passes down on either side of the epiglottis and uvula into the oesphagus1. The stomach lies horizontally across the upper abdomen at birth and increases its capacity from approximately 30ml to 500ml during the first year of life. The remainder of the gastrointestinal tract grows at a slower pace, the small bowel doubling its length between birth and puberty. The small and large bowel are both thin walled at birth due to the under- development of musculature and therefore radiological differentiation in the young infant can be difficult as the characteristic colonic haustrations and small bowel valvulae conniventes may not be apparent. In addition, little of the small bowel lies within the pelvis until after 2 years of age due to the small size of the infant pelvis. Extending from the kidneys bilaterally are the ureters, which open inferi- orly into the posterior aspect of the base of the urinary bladder. The urethra extends from the neck of the bladder to the exterior and is longer in the male than in the female. The kidneys are not fully functional at birth and glomerular filtration within the first year of life is relatively poor1. Growth of the kidneys is dependent upon the amount of work they do and evidence for this is the excessive or compen- satory growth of one kidney if the contra-lateral kidney fails to function correctly or is removed. The urinary bladder lies predominantly within the abdomen at birth with relative movement inferiorly as the pelvic cavity enlarges.

J Bone Joint Surg (Br) 75: 439–54 dystrophiekontraktur-prophylaktische Operationen der unteren 29 order depakote 250 mg overnight delivery symptoms in spanish. Smith AD depakote 500 mg mastercard symptoms 5 days before your missed period, Koreska J, Moseley CF (1989) Progression of scoliosis Extremitäten unter besonderer Berücksichtigung anaesthesiolo- in Duchenne muscular dystrophy. Smith SE, Green NE, Cole RJ, Robison JD, Fenichel GM (1993) enne muscular dystrophy. Arch Orthop Trauma Surg 114: 106–11 Prolongation of ambulation in children with Duchenne muscular 7. Furumasu J, Swank SM, Brown JC, Gilgoff I, Warath S, Zeller J (1989) dystrophy by subcutaneous lower limb tenotomy. J Pediatr Or- Functional activities in spinal muscular atrophy patients after spi- thop 13: 336–40 nal fusion. Gamble JG, Rinsky LA, Lee JH (1988) Orthopedic aspects of central a program for long-term treatment of Duchenne muscular dystro- core disease. J Bone Joint Surg (Am) 78: 1844–56 Subject Index Bold letters: Principal article Italics: Illustrations 756 Subject Index Acromesomelic dysplasia 664 – in congenital deformity of the lower A Acrosyndactyly 472, 477 leg 311 Adamantinoma 355, 587, 608, – mid- and rearfoot 402 Abducent nerve paresis 695 620–621, 634 – Syme 402 Abducted pes planovalgus 433–437, Adamkiewicz artery 115 – upper extremity 477 723, 726 Adaptation 50, 743 Amyloidosis 582 – functional 432, 437 Adaptive mechanism 743 Anaerobes 570 – structural, neurogenic 435 Adduction contracture Analysis, gait Abduction, examination 180 – hip 210, 212, 235, 237, 245, 266 see Gait analysis Abduction contracture Adductor tenotomy 236, 241 Andersen classification, congenital – hip 237, 245 Adhesion, spinal cord 739, 742 Pseudarthrosis of the tibia 314 abduction pants 186 Adolescence 6–7, 44, 68, 216, 285, Andry, Nicolas 16, 17 Abduction splint 213, 728 395 Anesthesia 21, 711, 712 see also Orthosis Adolescent’s kyphosis Aneurysmal bone cyst 522, 524, 587, Abilities, maintenance of 25 see Scheuermann’s diesease 586, 587, 590, 603, 605, 632, 634 Abnormality, congenital Adolescent scoliosis – lower leg 449, 450. Editor Clinical Assistant Professor and Residency Program Director Director, JFK Medical Center Consult Service Department of Physical Medicine and Rehabilitation University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School JFK Johnson Rehabilitation Institute, Edison, New Jersey Demos Medical Publishing, 386 Park Avenue South, New York, New York 10016 © 2004 by Demos Medical Publishing. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, elec- tronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Library of Congress Cataloging-in-Publication data Physical medicine and rehabilitation board review / by Sara J. However, Demos Medical Publishing cannot be held responsible for errors or for any consequences arising from the use of the information contained herein. The spirit, integrity and grace she brought to her patients and the field of Physical Medicine and Rehabilitation is greatly missed since she died of breast cancer at the young age of 36. This book is also dedicated to: my husband Alec (my loving partner in life); my four children, Michelle, Alexander, Amanda, and Nicholas (who are the joys of my life); my parents, Connie and Pat Cuccurullo, (my support system throughout my entire life); my mentors and teachers, especially my chairman Dr. Strax (my inspira- tion and supporter in all aspects of medicine both clinical and academic), and Dr. Johnson (my encouragement to take on a challenge); and the residents of the UMDNJ, Robert Wood Johnson Medical School, JFK Johnson Rehabilitation Institute Residency Program (whose hunger for knowledge inspired the concept of this review book). It is only because of the support and encouragement of these people that this project could be completed. PRODUCTION STAFF JFK Johnson Rehabilitation Institute Project Manager: Heather Platt, B. DM Cradle Associates, Publishing Services Project Manager: Carol Henderson We gratefully acknowledge the contributions made by the artists involved in this project. We sincerely thank them for their dedication, expertise, creativity and professionalism. Special thanks to Bob Silvestri and the JFK Johnson Rehabilitation Institute Prosthetic and Orthotic Laboratory. Over these years, I have had many requests for my yearly revised notes from former residents and from residents outside our program. For this reason I gathered together an expert group of knowledgeable physicians to put together a compre- hensive PM&R board review text. The Physical Medicine and Rehabilitation Board Review reflects the commitment of the authors and the faculty in the Department of Physical Medicine and Rehabilitation at UMDNJ Robert Wood Johnson Medical School, based at JFK Johnson Rehabilitation Institute, to produce a text that would be used as a guide containing selected topics considered impor- tant for physicians preparing for either the certifying or the recertifying examination offered by the American Board of Physical Medicine and Rehabilitation. This text presents clear prac- tical information for both residents studying for the boards of PM&R and for practicing physicians. This text should be of great value in not only preparing for the American Board of PM&R board exam, but also for caring for patients. The credit for this textbook coming to print must be given to Thomas Strax, M. His constant encour- agement and willingness to support this project has been a true inspiration in seeing this text- book come to realization.