Midamor

By Y. Rozhov. Barton College.

About 8% of African Americans have one of the blood and thus impaired delivery of oxygen to the tis- genes for the abnormal hemoglobin and are said to have sues discount 45 mg midamor overnight delivery blood pressure 8660. These disorders are characterized by an abnormal tendency to bleed due to a breakdown in the body’s clotting mechanism buy midamor 45mg without a prescription arrhythmia icd 9 2013. Anemia Anemia may result from loss of red cells, as through ex- Sickle- cessive bleeding (hemorrhage), or from conditions that shaped cause the cells to hemolyze (rupture). In other cases, cell bone marrow failure or nutritional deficiences impede the production of red cells or hemoglobin. Abnor- mal cells take on a crescent (sickle) shape when they give up Excessive Loss or Destruction of Red Cells He- oxygen. Philadelphia: Lippincott Williams morrhagic loss of red cells may be sudden and acute or & Wilkins, 2003. The average adult has about 5 liters upper left corner of this picture? If a person loses as much as 2 liters suddenly, between the cells? It is only when the involved gene is that may injure the marrow include x-rays, atomic radia- transmitted from both parents that the clinical disease tion, radium, and radioactive phosphorus. About 1% of African Americans have two of The damaged bone marrow fails to produce either red these genes and thus have sickle cell disease. One drug or white cells, so that the anemia is accompanied by has been found to reduce the frequency of painful crisis leukopenia (lu-ko-PE-ne-ah), a drop in the number of in certain adults. Removal of the toxic agent, followed by blood some hemoglobin of an alternate form (fetal hemoglo- transfusions until the marrow is able to resume its activ- bin) so that the red cells are not as susceptible to sick- ity, may result in recovery. People taking hydroxyurea require blood tests every have also been successful. Some Impaired Production of Red Cells or Hemoglo- medications are now available to stimulate bone marrow bin Many factors can interfere with normal red cell pro- production of specific types of blood cells. Anemia that results from a deficiency of some nu- EPO made by recombinant methods (genetic engineer- trient is referred to as nutritional anemia. These conditions ing) can be given in cases of severe anemia to stimulate may arise from a deficiency of the specific nutrient in the red cell production. Deficiency Anemia The most common nutritional ane- Leukemia mia is iron-deficiency anemia. Iron is an essential con- Leukemia is a neoplastic disease of blood-forming tissue. The average diet usually provides It is characterized by an enormous increase in the num- enough iron to meet the needs of the adult male, but this ber of white cells. Although the cells are high in number, diet often is inadequate to meet the needs of growing they are incompetent and cannot perform their normal children and women of childbearing age. A diet deficient in proteins or vitamins can also result As noted earlier, the white cells have two main in anemia. Folic acid, one of the B complex vitamins, is sources: red marrow, also called myeloid tissue, and lym- necessary for the production of blood cells. If this wild proliferation of white cells stems ficiency anemia occurs in people with alcoholism, in eld- from cancer of the bone marrow, the condition is called erly people on poor diets, and in infants or others suffer- myelogenous (mi-eh-LOJ-en-us) leukemia. When the ing from intestinal disorders that interfere with the cancer arises in the lymphoid tissue, so that most of the absorption of this water-soluble vitamin. Both types of by a deficiency of vitamin B12, a substance essential for leukemia appear in acute and chronic forms. The cause is a permanent de- The cause of leukemia is unknown. Both inborn fac- ficiency of intrinsic factor, a gastric juice secretion that tors and various environmental agents have been impli- is responsible for vitamin B12 absorption from the in- cated. Among the latter are chemicals (such as benzene), testine. Neglected pernicious anemia can bring about x-rays, radioactive substances, and viruses. In addition, they have a tendency to bleed easily, cord. Early treatment, including the intramuscular in- owing to a lack of platelets.

ROBERT J PETRELLA Introduction Persons with chronic conditions of ageing such as osteoarthritis comprise a large and growing proportion of the population 45 mg midamor visa hypertension age 70. Certainly generic 45 mg midamor with visa blood pressure chart poster, patients with osteoarthritis can improve pain control, proprioception, strength, instability and endurance, all of which will improve functional independence with regular exercise. Until recently, however, evidence regarding exercise and osteoarthritis has been equivocal. This perception may have limited the use of exercise for these patients, despite published guidelines, including those of American College of Rheumatology. For the purpose of this review, we have limited the scope to the knee, which includes the bulk of the evidence related to exercise to date. Treatment guidelines for osteoarthritis of the knee have considered exercise therapy as an important non-pharmacological treatment approach. Since the publication of treatment guidelines mentioned above6, several new randomised trials of exercise therapy for osteoarthritis of the knee have been published. This paper describes the current evidence for exercise in the treatment of osteoarthritis of the knee. Effort has been made to identify key determinants of effect including elements of the training programme, quality of studies and appropriateness of the outcome measures used. Methods What materials were used in the literature search? Comprehensive computer assisted search of medical, sport and rehabilitation literature (between June 1966 and January 2000) was conducted using Medline search systems. Highly sensitive search strategy of randomised controlled trials8 and systematic reviews was used. References of relevant review articles and trials were screened to identify references not contained in the main search. The search for literature was conducted using the MeSH headings and textwords (tw) of osteoarthritis or arthritis and knee (MeSH), exercise or physical training (tw) (Table 11. What were the criteria for studies considered for inclusion? Exercise therapy was defined as a range of activities to improve strength, range of motion, endurance, balance, coordination, posture, motor function or motor development. Exercise therapy can be performed actively, passively, or against resistance9. No restrictions were made as to type of supervision or group size. Trial reports were excluded if 1) they concerned peri-operative exercise therapy, or 2) intervention groups received identical exercise therapy and therefore no contrast existed between intervention groups. No restrictions were made concerning the language of publication. Sixty-seven publications were initially identified (Table 11. Thirty- seven studies were excluded because of methodological criteria, eight studies were excluded as they included review material, four concerned peri-operative exercise therapy and two included data reported in previous publications. Consequently, 16 publications concerning 19 trials (Table 11. As a consequence of the nature of exercise therapy neither care providers nor patients can be blinded to the exercise therapy. The most prevalent shortcomings of exercise interventions concerned co-interventions: the design of nine trials did not control for co-interventions concerning physical therapy strategies or medications and in eight trials there was no report of these co-interventions. Many trials lacked sufficient information on several validity criteria: concealment of treatment allocation, level of compliance, control for co-interventions in the design, and blinding of outcome assessment. Information on adverse effects of exercise therapy of long-term (greater than six months after randomisation) outcome assessment was often missing in trial reports. In three trial reports, long-term follow up was mentioned but no results were presented.

There has been widespread use of casting to reduce equinus in children with CP buy midamor 45mg without a prescription hypertension. Casting has had periods of enthusiastic promotion order midamor 45mg mastercard blood pressure medication beginning with a; however, no study has demonstrated any long-term benefit. Because casting is simple and cheap, it is still promoted by some82 (Figure 11. Recently, there has been an in- creased interest in combining the use of cast immobilization with botulinum toxin injections because both are recognized to relapse quickly. There has been a debate of the relative merits of repeated casting to treat equinus contractures of the ankle. This is often presented as the low-risk approach; however, the impact of casting is significant muscle atrophy and therefore creation of a small muscle mass. The tension of casting has never shown that it adds muscle fiber length, but if it does, it also adds tendon length. The impact of surgical tendon lengthening is a longer tendon and a muscle with no change in fiber length. If casting works, then the trade-off of the effects of casting versus sur- gery are still not clearly defined, because our goal is to have a strong, meaning large-mass, muscle with a long fiber length giving large active joint range of motion. Knee, Leg, and Foot 717 is a sense that combining these two modalities would provide longer-term benefit. At this time, there is no published evidence to support this concept. Complications of Treatment Complications of lengthening the gastrocsoleus complex are primarily re- current contracture or overlengthening. Wound infections are rare, and when they occur, they are easy to treat with local wound care. Spreading scars, which are sensitive to local touch, do occur but are almost completely avoid- able by not placing the incision directly posterior, where it is irritated by shoe wear. The incision should always be kept on the medial side, where it is less likely to be irritated and the spreading scar is also less noticeable. Recurrent contracture is by far the most common problem following equi- nus contracture surgery. The goal should not be to completely avoid recurrent contractures, although reducing the number and frequency is reasonable. Equinus surgery is very similar to treating an inflamed appendix. There is a well-recognized incidence of removing normal appendices because of mis- diagnosis. The accepted incidence of surgically exploring a normal appendix is safer than allowing a much larger number of inflamed appendices to rup- ture, with some possibly going on to death from general sepsis. A recurrent equinus contracture is like removing a normal appendix; not desired, but a necessary aspect of the current treatment routine. Overlengthening is analo- gous to allowing individuals to develop severe sepsis with significant risk of death. Rates of recurrent contracture requiring repeat surgery ranging from 9% to 29% have been reported. Most studies reviewing the outcome either have short-term follow-up, or the studies are old with very poor evaluations; therefore, it can be concluded that there are currently no good numbers to document an acceptable rate of recurrence. Our current child population is variable, but overall, it is expected that 25% to 40% of children having equinus surgery in childhood will require a second procedure before to full maturity. Of the few children with severe early con- tractures that require surgery before age 5 years, almost all will need a second surgery. However, at the other end, those children who do not need the equi- nus surgery until late childhood or adolescence seldom need another surgery. If the second surgery is required, the same indications and procedures are used. Repeat fascial lengthening of the gastrocnemius is possible; however, there is a higher incidence of needing an open lengthening of the Achilles ten- don on the second surgery.

Given these arguments about pre-exercise stretching 45 mg midamor sale blood pressure ed, the reader should remember that stretching at other times may theoretically induce hypertrophy cheap midamor 45 mg blood pressure medication hydroxyzine,30–32 and if future evidence suggests this occurs, an increase in strength is likely to decrease injuries. This may explain the results of Pope et al which showed an increased risk if ankle ROM was decreased, but no effect of pre-exercise stretching over 11 weeks. In conclusion, the clinical evidence is consistent with the basic science evidence and theoretical arguments; stretching before exercise does not reduce the risk of injury and stretching at other times may or may not be beneficial. Further Note: In a recent article (Br J Sports Med 2001;35:103–108), the authors suggested in the text that ankle injuries are more frequent in people who did not stretch immediately before a game. However, the results (Tables 3 & 4) suggest the opposite: people who stretch immediately before a game had 2·6 times the risk of injury. The simplest way to understand this is that the coding is Yes = 1 for stretching, which is the same as that for “history of ankle sprains”. Both history of sprain and stretching before exercise had odds ratios above 1. If the authors say a previous sprain increases the risk of injury, then so must stretching before exercise. The authors did not reply to a request for clarification. Sample examination questions Multiple choice questions (answers on p 561) 1 The original study by Ekstrand et al suggested that stretching immediately prior to exercise is associated with a decrease in injuries. Which of the following interventions that are likely to prevent injury were also included in the experimental group as co-interventions? A Shin guards B Supervised rehabilitation C Warm-up D Education E All or none of the above 2 With regards to the number of studies examining whether stretching outside periods of exercise prevent injury or minimise the severity of injury: A 2 found it does and 2 found it does not B 0 found it does and 2 found it does not C 2 found it does and 0 found it does not D All studies used a cohort design E All or none of the above 3 Theoretical reasons why stretching prior to exercise would not decrease injuries include all of the following EXCEPT: A Tissues that are more compliant are associated with a decreased ability to absorb energy B The compliance of active muscle is related to the compliance of muscle during normal stretches C Most injuries occur during eccentric activity of the muscle, within its normal range of motion D Overstretching a muscle is known to be a cause of muscle injury E All or none of the above Essay question 1 Discuss the evidence for and against the use of stretching immediately prior to exercise as an intervention to prevent injuries. Acknowledgements The author would like to acknowledge that some of this material has been previously published in the Clinical Journal of Sport Medicine Vol 9(4): 221–227, 1999, and in the Physician and Sports Medicine Vol 28(8): 57–63, 2000. Overall, stretching before exercise does not prevent injury. Note that most studies done on recreational athletes or military personnel. According to the basic science of injury, there is no reason why elite athletes would be expected to have different results. Does stretching outside 2 RCTs (n = 300–470), weaknesses in A1 periods of exercise follow-up and differences in baseline prevent injury? One study suggested a decreased injury rate and the other only decreased severity of injury. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Biomechanical responses to repeated stretches in human hamstring muscle in vivo. Passive energy absorption by human muscle-tendon unit is unaffected by increase in intramuscular temperature. Optimal duration of static stretching exercises for improvement of coxo-femoral flexibility. Effect of duration of passive stretch on hip abduction range of motion. The effect of heat and stretching on the range of hip motion. Repeated passive stretching: acute effect on the passive muscle moment and extensibility of short hamstrings. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle. Sport stretching: effect on passive muscle stiffness of short hamstrings. Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Electromyographic investigation of muscle stretching techniques. Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity.

For example effective 45mg midamor blood pressure reading 400, a 2- to 3-year-old child who This change concentrates the muscle force- generating ability into a very narrow range is 90 cm tall may have a gastrocnemius with a radius that is approximately of joint motion (A) generic midamor 45mg with visa blood pressure 60 over 0. In addition, many chil- one half of what it will be at maturity when he is 180 cm tall (Figure 7. By maturity, decreased ability to generate maximum force. The muscle can generate 2 kg tension force per square centi- tension of the length–tension curve to be de- creased (B). Therefore, the 90-cm-tall boy weighing 12 kg generates 25 kg of force in his gastrocsoleus, whereas by adulthood he will generate only 100 kg of force for a 70-kg weight. This means the power of his gastrocsoleus will drop from more than 200% of body weight to 140% of body weight. This percent drop also demonstrates the importance of avoiding severe obesity because this same individual will only generate the same amount of gastroc- soleus force if he weighs 70 kg or 100 kg; this has significant implications when comparing toe walking in a 3- or 4-year-old with toe walking in an adult-sized individual. This force discrepancy is one reason why adults are not long-distance toe walkers in the same way many younger children are. As children grow, the cross-sectional area of their calves grow at approxi- mately the same rate as height, and the area of muscle is defined by the radius. However, weight is defined by the expansion in length and width, which mathematically means it is the cube of expansion. Therefore, most young children generate high force for their weight, and as they grow older and heavier, their force-generating strength-to-weight ratio gradually de- creases. Here, muscle strength is defined as the force-generating ability of a muscle, which is also impacted by repeated heavy loading. As a muscle ex- periences load, it increases the cross-sectional area of the muscle fibers as the primary mechanism of increasing muscle diameter. If a muscle is not used, the diameter of the muscle decreases as it thins the muscle fiber. This change implies that the body wants to avoid carrying extra muscle mass that is not needed. Therefore, muscle strength is increased with resistive weight train- ing in which work and power are expended, although isometric contractions also increase muscle girth. Children with CP are generally weaker, specifically meaning they have an inability to generate tension in the muscle. The inability of the neuro- logic system to cause coordinated contraction of all motor units in the same muscle may be another reason. As these children grow and the effect of in- creased mass becomes more problematic, there is a major boost in muscle mass and cross-sectional area development with the onset of puberty. Only at this time is there a measurable difference in the strength of the muscle. The growth hormones and androgens stimulate this development, which occurs at some level in nonambulatory children as well. The impact of testosterone is more dramatic than estrogen; therefore, males have larger and stronger muscles. Muscle-strengthening exercises as a treatment of muscle weakness, which is present in almost all children with CP, have traditionally been contraindicated because the effects of spasticity might be worse. This theory is clearly false and is related in part to misunderstanding strength. The strength of a con- traction of a muscle or joint defined as the ability to move the joint against resistance during a physical examination has little relationship to the active force generated by an isolated contraction of a specific muscle. Recent work by Damiano and associates has shown that it is possible to do weight resistive training with children with CP, and also that there is a measurable increase in muscle force-generating ability with no recognizable side effects. Some functional gain may develop, which is true especially for situations such as following surgery or casting where children have developed disuse atrophy. Muscle Excursion Muscle excursion is the difference between the maximum shortening and maximum lengthening of a muscle. As a muscle’s physical length shortens, the associated joint loses range of mo- tion.