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By: Bertram G. Katzung MD, PhD

  • Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

http://cmp.ucsf.edu/faculty/bertram-katzung

Using reliable online and print resources buy tibofem 2.5mg lowest price, research your sport to tibofem 2.5mg generic find injury statistics cheap tibofem 2.5mg with amex. It is usually associated with cold weather tibofem 2.5mg, but it when you participate in also can result from lengthy exposure to wind or rain or from outdoor activities. When hypothermia occurs, the sunscreen in both hot body loses the ability to warm itself. If you begin to feel cold or to shiver, go to a warm, dry place; wrap your self in a blanket; and drink warm liquids to slowly raise your body temperature. Protecting Yourself from Sun and Wind Prolonged exposure to sun and wind is another weather related risk of outdoor physical activity. Windburn occurs when skin is exposed to freezing wind, causing it to become red, tight, and sore to the touch. In addition to increasing the risk of sunburn, repeated or prolonged exposure to the sun speeds the skin’s aging process and increases your risk of developing skin cancer. To protect yourself against sunburn: Cover as much of the body with clothing as possible when skin cancer For more infor outdoors and wear broad-brimmed hats on sunny days. Apply sunscreen 30 minutes before you go outside, spreading it liberally and evenly over all areas of your skin that will be exposed. A cataract, a cloudy covering over the lens of the eye, is caused in part by sun exposure. Wear a visor or a hat with a brim, and use sunglasses, even during the winter months. Lesson 5 Physical Activity Injuries 101 Ligaments are strong Minor Injuries bands of tissue that connect the bones to ave you ever had sore muscles after a physical activity or one another at a moveable experienced the pain of a twisted ankle Warming up, cool these bands are stretched ing down, and stretching can prevent or reduce muscle soreness. Other minor injuries that affect the skeletal or muscular systems include muscle cramps, strains, and sprains. Treatment for Minor Injuries Minor injuries such as muscle cramps, strains, and some sprains are easily treated. Major Injuries ain—especially extreme pain—may signal that you have a major P injury. If you experience extreme pain, numbness, or disorien tation or hear a “cracking” sound during a fall, get appropriate medical treatment immediately. The bandage should not injuries can be treated be so tight that it cuts off the blood supply to the area, and it by following the R. A fracture causes swelling and often extreme type of serious injury pain, and it usually requires immobilization to heal might the face mask properly. A physician must put the bone back into place and immobilize the joint so that the tissue can heal. This is a condition in which the tendons, bands of fiber that connect muscles to bones, are stretched or torn from overuse. Concussions result from blows to the head and can cause swelling of the brain, resulting in unconsciousness or even death. If you receive any blow to the head and experience headache, dizziness, or loss of memory or consciousness, see a health care professional immediately. Identify which injuries described in this lesson require the attention of professional health services. Explain why muscle cramps might be more dangerous for a swimmer than for a jogger. In this activity you will explore advertising techniques and evaluate the effectiveness of a fitness product. Note any key statements describing Write a paragraph expressing your the product’s advantages. How much of what is the advertiser provide about being advertised is based on accu using the product Explain whether how often must a person use you think the product might provide the product in order to get the any fitness benefits, and compare desired results Does claims were exaggerated, include this person lend any credibility suggestions on how the advertiser to the advertiser’s claims One of the earliest examples while swimming laps” or “straining and puffing while of organized exercise is the Olympic Games in 776 on a daily jog” are examples of phrases that illustrate B. At these first Games, the Greeks hosted just the sensory details of physical activity. Focus on design a visual aid, like a poster, to present your find using adjectives, adverbs, and action verbs. There are three different types amount of energy required to lift a 1-pound object of muscles in the human body: skeletal, smooth, and one foot. Skeletal muscles are used for voluntary motion food energy as well as the energy used by the body. Walking up one flight the involuntary activities of the body, controlling move of stairs is equal to lifting yourself 10 feet. How many ment in the heart (cardiac), arterial, and digestive sys calories would a 180-pound man use walking up one tems. Sports Medicine Would you like to work with athletes and others who lead physically active lives Physicians specializing in sports medicine treat injuries related to sports and other physical activities. To enter this profession, you will need to complete a four-year college program, four years of medical school, and from one to seven years of residency training.

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Crohn’s Disease Crohn’s disease is a chronic relapsing buy tibofem 2.5mg with mastercard, transmural granulomatous disorder cheap 2.5 mg tibofem with mastercard. It can occur anywhere in the gastrointestinal tract order 2.5 mg tibofem, from mouth to buy tibofem 2.5mg without a prescription anus, but is commonest in the termi nal ileum (hence its old name, ‘terminal ileitis’). It can affect the colon, where occasionally it may be difficult to differentiate from ulcerative coli tis. It will often affect separate areas of bowel with normal bowel in between (so-called ‘skip’ lesions). It tends to produce healing by fibrosis resulting in strictures and has a tendency to form fistulae to other struc tures, such as adjacent loops of bowel, the bladder, the vagina and the skin surface. The commonest presentation will be with a change in the bowel habit, usually diarrhoea, central abdominal colicky pains or pains in the right iliac fossa, fever, anorexia, weight loss and general malaise. On examination there may be tenderness or a mass in the abdomen, most often in the right iliac fossa. Investigation consists of the exclusion of other possible diag noses, including carcinoma. Blood tests may be helpful and show elevated acute phase proteins, especially C reactive protein. The mainstay of diag nosis, however, involves contrast studies (barium follow-through exami nation of the small bowel or barium enema for the colon) and endoscopic studies with biopsy. Most cases of Crohn’s disease are initially managed medically by gas troenterologists, although about 65% will at some time require surgery. Severe cases where there is stricture formation, fistualisation or an inflammatory mass that is not resolving, may need surgical intervention. The surgery for Crohn’s disease depends on which part of the bowel is affected and the treatment can be divided into surgery for small and large bowel disease. If the small bowel is predominantly involved, the main aims of surgery will be to perform stricturoplasties or resect the very diseased bowel locally but to minimise resection as much as possible. The reason for this is that occasional patients may require repeated surgery and end up with short gut syndrome if too much bowel is resected (the patients’ main con cern is liquid stools, although they also have all the vitamin and nutritional 138 Surgical Talk: Revision in Surgery deficiencies). In large bowel disease the operation usually performed is panproctocolectomy with ileostomy (removal of the whole large bowel and anus) or subtotal colectomy with ileorectal anastomosis (if the rectum is spared of disease). Smaller, more limited resections of the large bowel in Crohn’s are associated with high relapse rates requiring further surgery. Detailed questions about Crohn’s disease are most likely to come from gastroenterologists in medical exams. However, you should obviously know about the associated complications outside the abdomen, including the high incidence of perianal disease such as abscesses and perianal fis tulae, the skin changes of erythema nodosum and pyoderma gangraeno sum, the associated arthritis and ocular problems, etc. In more severe cases nausea, vomiting and distension may occur in association with pyrexia, and this should make one suspect the development of toxic megacolon. In nonacute cases investigation consists of the elimination of other pathologies, and confirmation is usually made by biopsy on sigmoi doscopy or colonoscopy. The figure usually quoted is that for ulcerative Small Intestine and Colon 139 colitis involving most of the colon there is a 10% risk of developing a carcinoma for every 10 years that the disease exists. The particular feature looked for on the biopsy is the development of dysplasia, and if it is severe, consideration should be given to the possibility of an elective total colectomy to reduce the risk of cancer formation. The operation will normally be a proctocolec tomy, which means that the whole of the colon and rectum will be removed so that no colonic mucosa will be left. After this the patient either is left with a terminal ileostomy or can have a new pelvic reservoir constructed (‘a pouch’), which is made by joining several loops of small bowel together and sewing that directly down to the anal sphincters. Such an operation cannot be offered to patients with Crohn’s colitis, because Crohn’s disease often recurs in the small bowel used to con struct the reservoir and the results of the operation are therefore poor. This is diagnosed on a plain X-ray and is defined as dilatation of the transverse colon above 6 cm. Initial attempts will usually be made to treat the patient conservatively with intravenous fluids, correction of electrolyte abnormalities and high-dose intravenous steroids. Repeated abdominal X-rays should be taken to watch the size of the colon (usually the trans verse colon), and if it appears to be getting bigger despite appropriate medical treatment an operation is indicated before it perforates. Also, if a perforation is suspected or if the patient fails to settle within 24–48 h of medical treatment, then surgery will be indicated. In this situation the usual surgical procedure is a total colectomy, an ileostomy and the rectal stump is usually oversewn or brought out to the 140 Surgical Talk: Revision in Surgery skin so that it can be inspected (this is called a mucous fistula). Subsequently, when the acute problem has settled, the patient could be offered an ileal reservoir or completion proctectomy. It is not uncommon to get shown a barium enema during your viva, and the commonest diagnoses are ulcerative colitis or an apple core stricture indicating malignancy. You may also get shown a barium meal with follow-through which looks at the small bowel (you see some contrast in the stomach and hence you can tell it is a follow-through), and this may show the strictures of Crohn’s disease. Patients who have had previous oper ations for colon cancer are often brought up as long cases. The way in which colon cancer presents depends partly on its position within the colon. Tumours on the right side of the colon are more likely to present later with a mass or anaemia, since the faeces are still liquid in this region and thus are less likely to produce an obstruction to the flow. In con tradistinction, tumours on the left side of the colon are more likely to pres ent early with obstruction and a change in the bowel habit.

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It is also one of the understand the components of the strokes buy tibofem 2.5 mg with amex, the most popular strokes purchase tibofem 2.5mg otc. He used the new stroke in 1902 at the stroke from South American Indians and introduced International Championships to order tibofem 2.5mg on-line set a new world it in England in 1873 tibofem 2.5mg on line. This stroke was the forerunner of the a front crawl stroke that took advantage of body front crawl. This led Australian Richard Cavill to try new methods of roll increased speed through the water and soon kicking. Likewise, most people who start learning to swim expect to learn it frst—and fast! Like all strokes, the front crawl has three characteristics: n the goal is effciency of motion. Hydrodynamic Principles Almost all the hydrodynamic principles discussed in Chapter 4 are involved in the front crawl. The front crawl, like other strokes, is a “feel stroke” in that the more Body roll is necessary to support the propulsion the swimmer “feels” the arms and legs pushing generated by the arms and legs. Body roll is a the water backward, the better he or she swims rotating movement around the midline of the forward. The focus of stroke mechanics is on body, an imaginary line from head to feet that sweeping arm motions that drive forward upon divides the body equally into left and right parts. During body roll, the whole body rotates as a unit, not just the shoulders, to each side about 30 It is also important to keep the body aligned in degrees from the surface of the water (Fig. Good body alignment makes these At the point of maximum rotation, the shoulder strokes more effcient. Any sideways movement stays next to the cheek and the body remains away from the body increases the resistance of facing more toward the bottom than to the side. Holding the head too the shoulder rotates below the cheek and in front high has a similar effect. Body Position, Balance and Motion Body roll is very important to several aspects of the body position of the front crawl is prone the front crawl. They should look down toward the bottom of the pool with the head in a relaxed position just as when standing up straight. The back of the neck remains fat and the water line is at the middle of the top of the head (Fig. Keeping the head facing down and relaxed helps keep the hips and legs at the surface and allows for effcient swimming. This part of the arm stroke is drives forward during the entry, body roll helps called the catch because it feels like grabbing a maintain the body’s forward movement. Bend the a person standing on the ground and pulling a elbow so that the palm and forearm face toward rope with outstretched arms generates more force the feet and press backward, fngertips pointing by rotating the hips. A swimmer can generate more force move naturally, just outside the shoulders, as the with each arm if the body rolls during each arm arm travels backward. The body starts to rotate along the midline as the legs also affect body position. When position can cause a poor kick, and a poor kick the hand is pitched effectively and the body is can cause poor body position. In an effective kick, allowed to roll, the catch seems to lead the body the heels just break the surface of the water and forward automatically. During the mid-pull, continue pressing the palm Arm Stroke and forearm directly backward. The hand follows Power Phase a path straight backward that traces the side of the power phase of the arm stroke consists of the body. The power phase hand so the elbow can remain bent and the palm begins by placing the hand into the water in front and forearm facing back. During the catch and mid-pull, push the water n Slide the fngers into the water frst with the palm backward and propel the body forward using the pitched slightly outward. As the arm moves water backward, n Keep the elbow partly fexed so that the point the body rotates so that the opposite hip moves of entry is about three-fourths as far as the arm toward the bottom surface. Think of this part of the stroke as the forearm Extend the wrist (bend it back) to keep the palm going through a hole that the hand makes in the pressing toward the feet while the fngertips water’s surface. The hands should be relaxed remain pointed toward the bottom until the arm is with the fngertips straight. Accelerate the hand from the catch to the fnish so that it is moving fastest at the end of the stroke. Completing the body rotation along the midline allows the arm to exit the water without obstruction. Recovery the recovery is not propulsive; it is simply a movement that puts the hand back in position for the next power phase. The most important point of the recovery is to keep the arm, hands and fngers relaxed. Lift the arm around the side of the body in a relaxed the elbow so that it is the frst part of the arm to motion, keeping the hand wider than the elbow. As you lift the elbow, keep As the hand passes the shoulder, let it lead the the arm relaxed with the forearm hanging down rest of the arm until it enters the water (Fig. The elbow should be the highest part Allow the body to rotate throughout the of the arm throughout the recovery, but not so recovery motion. For competitive swimmers, the distance the leg moves up and down—will vary however, the recovering arm can almost catch up with body type and fexibility. The cadence is More propulsion is generated from the arms than the number of kicks in an arm cycle.

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Despite the fact that trigeminal pain following minutes 3 herpes zoster probably leads to tibofem 2.5 mg with mastercard di erent types of patho 2 order tibofem 2.5 mg with amex. Therefore purchase tibofem 2.5 mg on line, the well-established a ected trigeminal distribution term post-herpetic neuralgia is maintained buy discount tibofem 2.5 mg on-line. A lesion or undue activation of these nerves (periph eral neuropathic pain), or of their central pathways (central neuropathic pain), causes neuropathic pain in Notes: the face. Inafewpatients,painmayradiatetoanotherdivision, the cause of a neuropathic pain may be clear, such but it remains within the trigeminal dermatomes. A minority of patients strated by imaging: such pain is termed secondary, will report attacks predominantly lasting for >2 and attributed to the cause. Some attacks may be, or appear to be, spontaneous, dius neuralgias, the term classical is reserved for cases but there must be a history or nding of pain pro where imaging or surgery has revealed vascular com voked by innocuous stimuli to meet this criterion. Strictly speaking, clas Ideally, the examining clinician should attempt to sical neuralgias are secondary (to the neurovascular con rm the history by replicating the triggering phe compression), but it is bene cial to separate them nomenon. However, this may not always be possible from other causes on the basis of the wider therapeutic because of the patient’s refusal, awkward anatomi options and potentially di erent nerve cal location of the trigger and/or other factors. However, in some, clinical neuro more divisions of the trigeminal nerve and triggered by logical examination may show sensory de cits, which innocuous stimuli. It may develop without apparent should prompt neuroimaging investigations to explore cause or be a result of another diagnosed disorder. When very severe, the pain often evokes contraction Previously used terms: Tic douloureux, primary trigeminal of the muscles of the face on the a ected side (tic neuralgia. Mild autonomic symptoms such as lacrimation and/ Diagnostic criteria: or redness of the ipsilateral eye may be present. Recurrent paroxysms of unilateral facial pain in refractory period during which pain cannot be the distribution(s) of one or more divisions of triggered. Recurrent paroxysmsofunilateral facial painful ll apparent cause other than neurovascular compression. Pain-free between attacks in the a ected trigem Diagnostic criteria: inal distribution. Comments: Nerve root atrophy and/or displacement due Description: Classical trigeminal neuralgia with persistent to neurovascular compression are independently asso background facial pain. When these anatomical changes Diagnostic criteria: are present, the condition is diagnosed as 13. Recurrent paroxysmsofunilateral facial painful ll the common site of neurovascular compression is at ingcriteriafor13. Concomitant continuous or near-continuous pain clearly associated with symptoms than compression by a between attacks in the a ected trigeminal vein. Atrophic changes may include demyelination, neuronal loss, changes in Comment: Peripheral or central sensitization may microvasculature and other morphological changes. While the exact mechanisms of how atrophic changes in the trigeminal nerve contribute to the generation of 13. An underlying disease has been demonstrated Between paroxysms, most patients are asympto known that is to be able to cause, and explaining, 1 matic. Recognized causes are tumour in the cerebellopon Description: Classical trigeminal neuralgia without per tine angle, arteriovenous malformation and multiple sistent background facial pain. Recurrent paroxysms of unilateral facial pain ful demonstrated lling criteria for 13. Description: Trigeminal neuralgia caused by an underly ing disease other than those described above. Recognized causes are skull-base bone deformity, connective tissue disease, arteriovenous malforma Diagnostic criteria: tion, dural arteriovenous stula and genetic causes of neuropathy or nerve hyperexcitability. Concomitant continuous or near-continuous pain between attacks in the a ected trigeminal Description: Trigeminal neuralgia with neither electrophy distribution. Recurrent paroxysms of unilateral facial pain ful more branches of the trigeminal nerve caused by another lling criteria for 13. The primary either purely paroxysmal or associated with con pain is usually continuous or near-continuous, and com comitant continuous or near-continuous pain monly described as burning or squeezing, or likened to B. As a rule, allodynic areas are much larger than the punctate trigger zones present in 1. Recurrent paroxysms of unilateral facial pain ful trigeminal nerve branch or branches, lasting <3 lling criteria for 13. The rst division of the trigeminal nerve is most Comments: Herpes zoster a ects the trigeminal ganglion commonly a ected in 13. Many patients, however, tingling or aching, and accompanied by cutaneous show little sensory loss, and instead demonstrate heigh allodynia. Description: Unilateral facial pain persisting or recurring Diagnostic criteria: for at least three months in the distribution(s) of one or more branches of the trigeminal nerve, with variable A. Facial and/or oral pain in the distribution(s) of sensory changes, caused by herpes zoster. History of an identi able traumatic event to the trigeminal nerve(s), with clinically evident positive A. Unilateral facial pain in the distribution(s) of a tri (hyperalgesia, allodynia) and/or negative geminal nerve branch or branches, persisting or (hypaesthesia, hypalgesia) signs of trigeminal recurring for >3 months and ful lling criterion C nerve dysfunction B. Evidence of causation demonstrated by both of nerve branch or branches the following: C. Usually, pain will have developed while the rash was still active, but on occasion later, after rash has Note: healed. In such cases, pale or light purple scars may be present as sequelae of the herpetic eruption.

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