By Q. Boss. University of North Texas.

Chest 102:347 discount silagra 100 mg on line, Adrop in FEV1 of at least 20% is diagnostic for EIA 1992 generic silagra 50mg fast delivery. Holzer K: Exercise in elite summer athletes: challenges for diag- Abronchodialator may be administered at the conclu- nosis. CHAPTER 24 DRUG TESTING 137 Mannix ET, Manfredi F, Farber MO: A comparison of two chal- Various studies suggest that 5–11% of high school lenge tests for identifying exercise-induced bronchospasm in males and 0. Provost CM, Arbour KS, Sestili DC, et al: The incidence of exer- This is not merely a problem of athletes: of the high cise-induced bronchospasm in competitive figure skaters. Rice SG, Bierman CW, Shapiro GG et al: Identification of exer- cise-induced asthma among intercollegiate athletes. Rundell KW, Im J, Mayers LB, et al: Self-reported symptoms and REGULATING AGENCIES exercise-induced asthma in elite athletes. INTRODUCTION DRUGS, MEDICATIONS, AND OTHER SUBSTANCES Drug testing of the athlete is an ethical, moral, legal, and occasionally medical issue. Use of ille- of drug testing separate from the therapeutic care for gal substance can be punished by criminal law. To prevent cheating by use of drugs and chemicals Components of these substances may be legal. To level the playing field by keeping clean athletes (Dronabinol is a derivative of marijuana and legal from having to compete with anabolic using ath- under prescription of a licensed physician. To prevent drug-induced illness and death Some legal substances can be used illegally. To prevent public-relations problems for teams and (Anabolic steroids are legal substances but can be organizations obtained and used illegally. SCOPE OF PROBLEM Some substances are legal but not allowed under cer- tain circumstance. Just because a medication is prescribed does POSTSEASON TESTING not exempt an athlete from sanctions. Many drugs courier and given a written notification form instruct- (legal and illegal, prescription and nonprescription) ing the athlete to accompany the courier to the collec- are based in natural products. The athlete must report within 1 h and even more, these products may not be fully labeled remain in visual contact with the courier until the ath- with all ingredients. RECREATIONAL DRUGS Sealed beverages without caffeine or other banned substances are allowed at the testing center. If the specific Stimulants such as amphetamine, cocaine, ephedrine, gravity is less than 1. If the pH is thamphetamine (MDMA or Ecstasy), and related greater than 7. PERFORMANCE ENHANCEMENTS The athlete selects containers and unique bar-coded labels. All is done in the Epogen and related compounds and blood doping are presence of the athlete. The specimen In addition, techniques to mask drug testing or fool drug must be controlled and signed every step in the process. These include diuretics, urine The specimens are sent to an approved laboratory for substitution, masking agents, and other techniques. The athletics director THE NCAA DRUG TESTING or designate is notified by overnight mail marked con- PROGRAMS) fidential, who in turn must notify the athlete. Different lab personnel will test testing, universal testing, or testing based on probable specimen B. CHAPTER 24 DRUG TESTING 139 INSTITUTIONAL DRUG TESTING LEGAL ISSUES Expect legal challenges to testing procedures and Extreme care must be taken to protect the rights of the especially to positive tests. If sent to an outside facility, the school or organization must assure BIBLIOGRAPHY that proper conduct and procedures are followed. Pediatr Clin North Am stances, health risks, treatment options, and sanctions 49(4):829–855, Aug 2002. Section 3 MEDICAL PROBLEMS IN THE ATHLETE Williams, 1997; Villeneuve et al, 1998; Kohl et al, 25 CARDIOVASCULAR 1992; Blair et al, 1995) have consistently confirmed CONSIDERATIONS the cardiovascular benefit of aerobic exercise with a Francis G O’Connor, MD, FACSM reduction in the number of adverse events and a reduction in mortality. John P Kugler, MD, MPH W hile there is a definite increased risk for certain sus- Ralph P Oriscello, 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).

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Narakas AO (1987) Plexus brachialis und nahe liegende periphere respect of the possible indication for surgery generic 50mg silagra with amex. The two Nervenverletzungen bei Wirbelfrakturen und anderen Traumen ossification centers of the coracoid and the 2–5 centers der Halswirbelsäule discount 50mg silagra with visa. Orthopäde 16: 81–6 in the acromion can occasionally lead to confusion and 16. Clin Orthop 237: 43–56 misdiagnoses, particularly if they persist as a bipartite or 17. Narakas AO (1993) Muscle transpositions in the shoulder and tripartite acromion. Rollnik JD, Hierner R, Schubert M, Shen ZL, Johannes S, Troger M, Most scapular fractures heal without complications with Wohlfarth K, Berger AC, Dengler R (2000) Botulinum toxin treat- temporary immobilization in an arm sling or a Gilchrist ment of cocontractions after birth-related brachial plexus lesions. Tona JL, Schneck CM (1993): The efficacy of upper extremity in- may be required, in rare cases, for glenoid fractures with hibitive casting: a single-subject pilot study. Am J Occup Ther 47: glenohumeral instability, scapular neck fractures in com- 901–10 bination with a clavicular fracture and displaced coracoid 22. Zancolli EA (1981) Classification and management of the shoulder fractures. Zancolli EA, Goldner LJ, Swanson AB (1983) Surgery of the spastic hand in cerebral palsy: report of the Committee on Spastic Hand Prognosis Evaluation (International Federation of Societies for Surgery of the The prognosis depends primarily on the additional in- Hand). Hasler front, the clavicle is straight, while from above it appears S-shaped with a forward-facing convexity in the middle 3. Given the absence of muscles on the anterior and Occurrence superior sections, the shape and length of the clavicles Apart from the spina scapulae, the acromion and the substantially determine the appearance of the shoulder coracoid, the scapula is deeply embedded on all sides in girdle. As a spacer between the acromion and sternum, it the protecting musculature. Scapular fractures are very rare and evidence of monest injury caused by birth trauma. In terms of prognosis, the latter The clavicle plays a key role in the functional are more decisive than the scapular fracture. Diagnosis Diagnosis Clinical features Clinical findings The clinical picture is dominated by the additional in- In children and adolescents the local pain over the clavicle juries to the skull, thorax and abdomen. Although rarely associated with finding locally is a painful restriction of movement of a clavicular fracture, a plexus palsy should be ruled out the shoulder, particularly from 70–90° of glenohumeral. The latter can also be induced by an excessively tight abduction, when the scapula starts to rotate as well. Imaging investigations Imaging investigations The conventional radiological presentation of a scapular AP x-ray of the clavicle. In view of the superficial position fracture on AP and Y views is occasionally inconclusive. Otherwise the absence of symptoms is evidence account for the highest proportion, by far, of all clavicular of consolidation. The younger the child, the more likely it is that the fracture will be non-displaced. Surgical Lateral fractures frequently correspond to epiphyseal Open reduction and internal fixation of shaft fractures is separations and, in clinical respects, resemble an acro- indicated only in exceptional cases: mioclavicular dislocation as seen in over 13-year olds or Shortening in excess of 2 cm after physeal closure. The risk of pseudarthrosis is higher during childhood and the cosmetic result is often experienced to be! In this case, the patient should be inferior section of the periosteal sleeve and the informed, preoperatively, particularly about the wide, adjacent coracoclavicular ligaments remain in- keloid-like scars that can often result. The outstanding osteogenic potential of the ▬ Open fractures or fractures with threatened penetra- periosteum leads to rapid consolidation and im- tion. Medial fractures are rare and represent epiphyseal separa- Pathological fractures. We prefer internal fixation with a small-fragment plate Treatment fixed to the clavicle from the bottom. Conservative Medial epiphyseal separations with retrosternal dislo- cation require emergency reduction, usually as an open! Displaced fractures with an ad latus deformity and short- All that is required for treating the pain, therefore, is ening result in a distinct bony bulge, which is often even immobilization in a simple arm sling for 2 weeks in com- more accentuated at a later stage as a result of marked bination with oral analgesics for 3–4 days. Both the bulging and the shortening after a figure-of-eight strap and an arm sling are identi- remodel themselves if the growth plates are still open, cal. Depending on the severity of the symptoms, arm- although this takes from 6–12 months. Informing the par- hanging exercises may be initiated independently after ents and the patient accordingly will prevent additional just 1–2 weeks. For initially displaced fractures, an x-ray consultations and unnecessary corrective procedures. Apart from the few cases resulting from birth trauma, these fractures occur mainly in over 10-year olds. A conservative approach with early functional mal humeral epiphyseal plate, which appears roof-shaped therapy is particularly suitable for fractures of the from the front and flat from the side. However, such differences are of no Diagnosis therapeutic importance, and very rarely of any prog- Clinical features nostic significance, since relevant growth disturbances Pain in the area of the proximal humerus. The hyperextension traumata lead to tilting in the Imaging investigations dorsal direction, but rarely to instability. Depending on the forced posture Epiphyseal fractures (Salter types III and IV) and avulsion produced by the pain, the proximal humerus may not ap- fractures of the lesser tubercle are rare, as are subcapital pear to be affected from the front on the AP view or from fractures in combination with glenohumeral dislocation a strictly lateral position on the Y view. Ad latus deformities by the full shaft width and shortening of up to 2 cm. Comprehensive briefing of the parents and patient about the biological and chronological processes of spontaneous remodeling of untreated deformi- ties is very important in order to avoid unnecessary »medical tourism« or even surgical interventions. Conservative After 1 or 2 weeks of immobilization in an arm sling or, if the condition is painful, in a Gilchrist bandage, the patient is given instruction on mobilizing the shoulder indepen- dently with active and passive arm-hanging exercises.

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Once the editorial committee receives the reviewers’ comments buy silagra 50 mg without prescription, they classify the paper into one of several categories as shown in Box 5 order silagra 100 mg line. Papers may be classified as unacceptable for publication on many grounds including poor science or reporting, inappropriate length, non-original results or material that is not appropriate for the journal. Editors are usually quite explicit in their correspondence about the reasons for their decisions. As such, it is a confidential consultancy between the reviewer and the journal editor. In a study of papers sent out to 252 external reviewers, 123 Scientific Writing less than 6% of the reviewers were correctly identified by authors. This left reviewers free to make whatever criticisms they felt necessary. The editor then forwards the comments to the authors without the reviewers being directly accountable. This closed review system often comes under criticism, especially when authors feel that their manuscripts have been unfairly treated or even plagiarised. Interestingly, identification had no effect on the quality of the feedback received, on recommendations regarding publication, or on the time taken for the paper to be returned to the journal. Despite the finding that this system was not detrimental to the quality of reviews, this type of open review is rarely conducted and anonymity is usually retained. In an attempt to remove any bias due to lack of anonymity of authors to the reviewers, the Medical Journal of Australia conducted a trial of removing authors’ names from papers sent out for external review. Once the paper was accepted for publication, the author and the reviewers were asked to consent to both the paper and the critical feedback being posted on the internet. An evaluation suggested that this open review system had some benefits such as increasing the fairness of the system and increasing the depth of feedback as a result of a wide range of readers posting their comments on the website. With the facilities that the internet offers, it seems likely that other journals may move to more open review methods in the future. By the time I was sixteen, I’d begun to get rejections slips with handwritten notes a little more encouraging…. For some journals, you could hope to receive a letter with a preliminary decision within 3–4 months, but this process can often take much longer. If you have not received a reply after 4 months, a polite letter to the editor enquiring about progress is in order. Many journals try to expedite the review process by getting consent from reviewers before dispatching the papers and by requesting faxed or email responses. However, the turnaround time can sometimes be slow and papers have occasionally gone missing. It is very unusual to receive a letter that says that your paper has been accepted without some revisions being needed. The extent of the revisions requested can vary widely from minor additions to a radical shortening of the manuscript or inclusion of further analyses. If the required revisions were extensive, the editor may send your revised paper back to the external reviewers for further comments after you have made the changes. The process then starts again and may again bring acceptance, further suggestions for change, or rejection. Many journals set a time limit of 3 or 6 months in which they are prepared to accept an amended version. If you resubmit after this time, your paper will in all likelihood be considered as an original submission. The reviewers to whom we sent your paper have made some important comments. If you are willing to address their comments adequately in a revised version of your paper, we should be happy to accept it for publication. 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.

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