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Lateral radiograph demonstrating significant L5-S1 Recent studies have indicated that repetitive spondylolisthesis depakote 500 mg on line. The overall incidence of spondylolisthesis is higher in gymnasts generic depakote 250mg with amex, football linemen buy discount depakote 500mg on line, wrestlers purchase depakote 500 mg with mastercard, and dancers generic 500 mg depakote with visa. There is no question that spondylolytic spondylolisthesis is a significant cause of backache in children and adolescents and often of disabling proportions. Clinically the patients will present with lumbar back pain, occasionally an exaggerated lumbar lordosis in the area of slipping, and hamstring tightness. Pain is generally elicited with forward bending and pressure on the spinous processes of L4 and L5. There may or may not be neurologic Adolescence and puberty 88 findings of sciatic stretch in the lower extremities. Clinical suspicion should prompt radiographic examination to reveal the spondylolytic defect, or true spondylolisthesis. Radionucleotide imaging currently is the most desirous means of establishing a diagnosis of spondylolysis. Computed tomography (CT) scanning can be useful in further delineating the extent of the defect and in following any potential healing of the defect in those cases of “acquired” stress fracture. In general, conservative back programs are used for minimal degrees of slipping. Occasionally spinal orthotics are used and surgical stabilization or reduction of the degree of the slipping may be necessary for more severe Figure 5. The head to neckrelationship in acute slipped capital femoral degrees of spondylolisthesis or chronic epiphysis. Slipped capital femoral epiphysis Slipped capital femoral epiphysis, is a disorder of puberty characterized by slipping (movement) of the femoral head off the femoral neck. The femoral head ultimately migrates into a position of posterior–inferior displacement relative to the femoral neck. Lateral radiograph demonstrating bilateral slipped capital femoral epiphysis. Proponents of the mechanical theory believe that excessive body weight, seen commonly in this condition, wears out the ability of the physis to withstand the mechanical forces applied to the growth plate. By overloading, the growth plate slowly or abruptly yields to excessive body mass, resulting in slipping of the head off the femoral neck. A contrasting hypothesis suggests that 89 Slipped capital femoral epiphysis the growth plate is weakened, due to a delicate imbalance between the hormones of puberty, coupled with an oblique shape to the growth plate, and excessive body mass, leading to gradual or abrupt slipping of the femoral head. This theory suggests that there is a basic hormonal imbalance at puberty that weakens the growth plate as a predilection to slipping. Slipping usually is seen in females between 10 and 15 years of age or in males generally between 12 and 16 years of age. Males are affected slightly more often than females, in a three to two proportion. The degrees of slipping inslipped capital femoral epiphysis has been estimated to occur in 25 percent of compared. Chronic slipping, where the head is anchored well to the femoral neck (stable), is seen far more commonly than acute slipping (90 percent), in which the femoral head is mobile on the femoral neck (unstable). The degree of slipping of the femoral head off the femoral neck is generally graded as to the amount of head displaced in proportion to the width of the femoral neck (Figure 5. Slips are generally graded as mild, with up to 30 percent displacement of the femoral head on the neck, moderate or grade two, with 30–50 percent displacement of the femoral head on the neck, and severe, with greater than 50 percent of the head displaced on the femoral neck. Histologic examination of growth plates affected by slipping have shown a general disorganization of the growth plate, with an acceleration of the chondroblast cell turnover (apoptosis), and a reduced amount and poor orientation of the collagen in the hypertrophic zone of the growth plates. In spite of these histologic abnormalities, little has been contributed to the actual discovery of the etiology, and it is still not known whether this condition is based on a purely mechanical disorder of the growth plate or a biochemical disorder. It is highly likely that the etiology is multifactorial with a preponderance of evidence favoring a “disorder” of puberty. The clinical picture is characterized by an antalgic limp, seen in the adolescent age group, Adolescence and puberty 90 with pain generally referred along the anteromedial aspect of the thigh to the knee. The degree of limitation of range of motion clearly depends on the severity of slipping.

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Ho and Ong (2001) used Singapore purchase depakote 250mg with amex, a large multiethnic society discount 250 mg depakote amex, to ex- amine the influence of group membership (Chinese cheap 500mg depakote with mastercard, Malay discount 500 mg depakote with mastercard, Indian cheap depakote 500mg otc, and other) on headache morbidity. No significant ethnic differences were found for lifetime or current headache prevalence within a sample of over 2,000 in- dividuals, although there were some group differences in average headache intensity and frequency, with the Chinese lowest. Non-Chinese were also more likely to seek medical attention for their headaches and to have taken medical leave during the preceding year. The data do not allow one to de- termine whether genetic factors may have influenced the outcome of this study. For the age range 45–64 years, musculo- skeletal pain prevalence was higher in all ethnic groups (about 70 to 90%) than in White subjects, with the latter being about 53% for both males and females. When asked whether they had pain in “most joints,” about 6 to 8% of Whites agreed compared to about 30 to 45% in the ethnic minority groups. The authors cautioned that comparable studies need to be done in other geo- graphical locations, because the data do not permit one to readily distin- guish between differences in pain sensitivity or expression, the effects of change of culture and migration, and mental health issues. With respect to the last point, a study (Nelson, Novy, Averill, & Berry, 1996) with a relatively small sample of Black, White, and Hispanic patients in a southern U. McCracken, Matthews, Tang, and Cuba (2001), in one of the few studies of ethnic or racial group differences in the experience of chronic pain, asked 207 White and 57 African American patients seeking treatment at a pain management center about their physical symptoms, depression, dis- ability, health care use, and pain-related anxiety. The two groups did not differ in age, education, or chronicity of their pain complaint. African Ameri- cans rated their pain higher and reported more avoidance of pain and activ- ity, more fearful thinking about pain, and more pain-related anxiety. As well, they were higher on physical symptom complaints and on physical, psycho- social, and overall disability. The authors noted that many factors may ex- plain these findings, including less social support, differences in social cir- cumstances, beliefs about pain, and self-management strategies, and the 170 ROLLMAN possibility that African Americans may not seek or be referred for treat- ment unless they are suffering from high levels of distress. A study by Jordan, Lumley, and Leisen (1998) compared pain control be- liefs, use of cognitive coping strategies, and status of pain, activity level, and emotion among 48 African American and 52 White women with rheuma- toid arthritis, controlling for the potentially confounding influence of in- come, marital status, and education. There were no group differences in pain, but the African American patients were less physically active and more likely to cope with pain by praying and hoping and diverting atten- tion, whereas Whites were more likely to make coping statements and ig- nore the pain. Bill-Harvey, Rippey, Abeles, and Pfeiffer (1989) had earlier noted that 92% of low-income, urban African American arthritis patients used prayer to relieve their pain and discomfort. Cognitive behavior ther- apy and other treatments that encourage the use of increased coping at- tempts and decreased negative thinking can aid African Americans to man- age experimentally induced pain (Gil et al. Waza, Graham, Zyzanski, and Inoue (1999) found that Japanese patients who had been newly diagnosed with depression reported more total symp- toms, particularly physical ones, than patients in the United States. Twenty seven percent of the Japanese patients reported only physical symptoms, whereas only 9% of the patients in the United States presented in this man- ner. A large proportion of the Japanese had pain complaints (generally ab- dominal pain, headache, and neck pain); comparable figures for the Ameri- can patients were about 60 to 80% less. The authors propose that pain at specific body areas may arise because of cultural influences, possibly to avoid the stigma in Japan associated with emotional disorders. For exam- ple, many Japanese expressions use the term hara (abdomen) to verbalize emotion, and digestive-system complaints are the primary reason for out- patient medical visits in that country. Njobvu, Hunt, Pope, and Macfarlane (1999), in a review of pain among in- dividuals from South Asian ethnic minority groups who live in the United Kingdom, observed that they more frequently attend medical clinics and re- port greater musculoskeletal pain. This leads to the question of whether South Asians also suffer greatly from pain in their countries of origin. Hameed and Gibson (1997) provided relevant data in a study of pain com- plaints among Pakistanis living in England and in Pakistan. Those living in England reported more arthritic symptoms and more nonspecific musculo- skeletal pain, particularly among females. There are numerous possible ex- planations including the colder British climate, adjustment to life in a new 6. ETHNOCULTURAL VARIATIONS IN PAIN 171 society, and a greater willingness to report pain among the better educated Pakistanis living in Great Britain. Sabbioni and Eugster (2001) also looked at immigrants, namely, Spanish and Italians living in Switzerland. Earlier studies had found that foreign pa- tients in that country had worse medical outcomes after back injury than Swiss ones, but the migrants often worked in low-paying jobs with in- creased health hazards.

For example order depakote 500 mg fast delivery, on 18 April 2000 depakote 500mg line, when technology stocks crashed wiping out $37 billion in personal wealth in Australia 500 mg depakote amex, the Daily Telegraph used the headline Crash discount 250 mg depakote with mastercard. In the scientific world order 250 mg depakote with amex, the following two journal articles relating to the human genome were published about the same time: The sequence of the human genome3 Initial sequencing and analysis of the human genome4 Although both are concise, the first title is shorter and thus more appealing. However, a scan of some medical journals shows that many titles are long and boring, and give the impression of being just another journal article that will be tedious to read. Rambling titles are usually convoluted and will not appeal to your external reviewers or improve your readership. Consider the two titles below: The effect of parental smoking on the development of asthma and other atopic diseases in children: evidence from a birth cohort study in NSW, Australia Parental smoking and the development of childhood asthma The first title is comprehensive and descriptive but contains just too many prepositions and qualifiers. For example, if you use the word development, then the method cohort study does not need to be added because development cannot be measured in any other type of study. Both titles convey the same message but the second title begins with the main subject of the study parental smoking and encompasses the scope of the paper in a few words. The title is much improved by the deletion of the unimportant and unnecessary words. However, one word of warning – you must always be accurate and specific in your choice of words and ensure that you do not extend your title beyond the scope of your paper. For example, a review entitled Respiratory health of Australians would be expected to contain a broad scope of information about many subjects relating to respiratory health, including information about infections, allergies, smoking outcomes, asthma, and chronic lung disease in both adults and children. On the other hand, a title such as Asthma and atopy in Australian children is more specific and may more accurately describe the scope of the review. Since people began to write papers, titles that begin with On have suggested something monumental and enduring. Now, many 95 Scientific Writing researchers aspire to having at least one On paper in their publication list. In writing a paper with colleagues about a significant advancement in the perplexing problem of defining asthma in population studies, we came up with the title Toward a definition of asthma for epidemiology. We were delighted when the paper and its title were accepted for publication and five years later had achieved a higher citation rate than the impact factor of the journal (4·7 versus 4·4). Impact factors, which are discussed in Chapter 6, are a method of rating the uptake of information presented in a journal article. A title such as The relationship between symptoms of asthma and airway hyperresponsiveness: results from a population study of children to describe the same paper may never have achieved such acclaim. Nevertheless, you can have only so many On and Toward papers on your resume. We used the title Busselton revisited7 to compare prevalence data from two population studies just at the time when the BBC series Brideshead revisited was enjoying high television ratings. Fellow researchers loved our title and we were runners-up to receive a prize for the work at a national conference. A long descriptive title such as Evidence for an increased prevalence of asthma in adults living in Western Australia: results from comparative studies in 1981 and 1992 would never have got us so far. Some examples of memorable titles from the literature are shown in Box 4. They are all short and concise but they also have an element of intelligence and/or wit. It is noteworthy that most have a qualitative subtitle that adds to, rather than detracts from, the subject. When browsing the web or undertaking a literature search, many researchers go in and read papers whose titles attract them. However, we acknowledge that you can enjoy far greater licence when designing titles for annotations, reviews, abstracts, and posters than you can for original journal articles. Recruitment in the Childhood Asthma Prevention Study16 African origin of modern humans in East Asia: a tale of 12,000 Y chromosomes17 Losing the battle of the bulge: causes and consequences of increasing obesity18 The titles of a journal article should have minimal punctuation. That said, for better or worse, punctuated titles have increased in popularity. The number of colons used in titles increased significantly in the BMJ and the Lancet between 1970 and 1995, but not in the New England Journal of Medicine. Writers often use punctuation to add a qualifying subtitle even though subtitles that describe the study design are often unnecessary or can detract from the title’s impact. For example, in the title Risk factors for birth defects in premature babies: a case–control study, the study design could be removed.

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