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By I. Ortega. University of Minnesota-Twin Cities.

The etiology of traumatic and constitutional shoulder Clinical features trusted doxycycline 200mg, diagnosis dislocations will be addressed jointly since constitutional Acute shoulder dislocation factors usually play a role in adolescents even in the pres- With an initial shoulder dislocation it is usually difficult to ence of adequate trauma. This presupposes that recur- establish whether predisposing factors are present or not. Often the opposite side will also dislocate whether an abnormal trauma producing substantial de- at a later stage following a traumatic dislocation. An anterior shoulder dislocation is pre- can occur at a later date even after a genuine traumatic dominantly caused by this movement direction, whereas dislocation. If the dislocation can be first dislocation: reduced spontaneously, it must be assumed that predispos- ▬ Lesions of the anterior glenoid rim: Small shell-shaped ing factors play a significant role. On the other hand, if the tears (Bankart lesion) or large shear fragments of dislocation cannot be reduced without medical assistance, the socket. The AP x-ray of the shoulder, and also the ity the indentation is usually located on the posterior Y-view ( Chapter 3. The humeral head is always in a caudal position, Moreover, an anterior dislocation can often be accom- regardless of whether the dislocation is in an anterior or panied by tearing of the ligaments with the glenoid posterior direction. As a result, the dislocation is always labrum, even without bone fragments. The situation is even clearer on the Y-view, which shows the glenoid from above. Ad- The following constitutional predisposing factors also ap- ditional imaging procedures are not indicated for the ply: acute form. The direction of movement at the time of the dislocation should be established.

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In managing chronic nonmalignant pain cheap doxycycline 100 mg with amex, most PCPs feel comfortable prescribing nonopioid therapies, such as all the classes of nonsteroidal anti- inflammatory drugs, Tylenol, and muscle relaxants, and nonpharmacologic treatments such as physical therapy. However, all PCPs have encountered patients for whom these medications and therapies are not enough and who require stronger medications in the form of opioids prescription. Multiple patient, physician, and system-related issues converge to make PCPs often uncomfortable about prescribing opioids for chronic nonmalignant pain (fig. Patient-Related Issues Patients with chronic nonmalignant pain often have no identifiable anatomic lesion that PCPs can point to as a clear cause of pain and that, in a doctor’s mind, better justifies the use of long-term strong opioid medications. Without objective evidence of pathology, there is less to counter the multi- ple forces that weigh in on the side of not prescribing opioids. If PCPs choose Opioids for Chronic Pain in Primary Care 139 Pressures against prescribing Fear of being duped Lack of clear guidelines Criminal justice Fear of addiction DEA system Productivity and time Controversy over effectiveness Patient characteristics: of opioids in chronic pain demanding, personality disorders, comorbid depression Primary care physicians Medical boards Desire to help Patients JCAHO Pharmaceutical companies Pressures for prescribing Fig. Pressures on PCPs against and for prescribing opioids for chronic nonmalig- nant pain. Research has shown that chronic pain patients tend to have a higher preva- lence of comorbid psychiatric disorders, such as depression and borderline personality disorders, and that the presence of these conditions is associ- ated with poorer pain control. Within the past 20 years, PCPs have improved significantly in their treatments of depression, but when depres- sion is combined with chronic pain and personality disorders, these patients often become complicated and frustrating. Prescribing opioids in these situa- tions is something PCPs usually might try to avoid although opioids may be the appropriate treatment depending on the diagnosis, and the type and chronicity of the patient’s pain. If patients feel that their pain is not adequately addressed, they may become demanding and sometimes can give the appearance of being drug-seeking or addicted when in reality they are not. If patients have a history of substance abuse, then the treatment of chronic pain becomes even more difficult for PCPs. This group of patients has almost 4 times the odds of exhibiting prescription opioid abuse behaviors compared to patients without a lifetime history of substance abuse. Often in these patients, however, it becomes difficult to distinguish whether the substance abuse, including prescription pain medicine addiction, came about as a Olsen/Daumit 140 consequence of chronic pain treatment or whether the substance abuse is exac- erbating the chronic pain symptoms.

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Carrithers JA order doxycycline 100 mg line, Williamson DL, Gallagher PM, et al: Effects of postexercise carbohydrate-protein feedings on muscle glyco- SUMMARY gen restoration. Nutrition for Sport A balanced diet that provides the proper amounts of and Exercise. This is especially impor- College of Sports Medicine position stand: Exercise and fluid tant for the athlete who might be training intensely or replacement. The three primary Coyle EF, Coggan AR, Hemmert MK, et al: Muscle glycogen uti- energy systems used during running are the power, lization during prolonged strenuous exercise when fed carbo- speed, and endurance systems. Coyle EF, Jeukendrup AE, Wagenmakers AJ, et al: Fatty acid oxi- used and energy requirements will vary for each indi- dation is directly regulated by carbohydrate metabolism during vidual depending on such factors as mode of activity, exercise. To aid Davis JM, Jackson DA, Broadwell MS, et al: Carbohydrate in peak performance it is recommended that the ath- drinks delay fatigue during intermittent, high-intensity cycling lete pay special attention to preevent, event, and in active men and women. This will help ensure Deuster PA, Day BA, Singh A, et al: Zinc status of highly trained adequate hydration, glucose intake, and recovery. Am J Clin Nutr Finally, the use of such methods as glycogen loading 49:1295–1301, 1989. National Academy of Sciences: Recommended Dietary Allowances, Fogelholm M: Indicators of vitamin and mineral status in ath- 10th ed. National Academy of Sciences: Dietary reference intakes for cal- Helge JW, Richter EA, Kiens B: Interaction of training and diet cium, phosphorus, magnesium, vitamin D, and fluoride. National Academy of Sciences: Dietary Reference Intakes for Houtkooper L: Food selection for endurance sports. Med Sci thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, Sports Exerc 24:S349–59, 1992. Washington, DC, Hurley BF, Nemeth PM, Martin WH, III, et al: Muscle triglyc- National Academy Press, 1998. J Appl National Academy of Sciences: Dietary reference intakes for vita- Physiol 60:562–67, 1986.

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