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This rapidly evolving specialty is based upon the exploitation of key principles of anatomy, physiology, pathology and surgery. Mastery of these principles as well as the acquisition of sound surgical technique enables plastic surgeons to constantly adapt to the wide variety of individual cases they face and provide functional and aesthetic solutions. Comprehensively describing and explaining all of the principles of plastic and reconstructive surgery would require far more space and time than can be afforded in a single chapter. This chapter will therefore focus on key principles that will allow non-specialists to understand the fundamentals of this specialty. The first section concentrates on the basic sciences of skin anatomy and the pathology of wound healing relevant to plastic surgery. The second section will evaluate practical plastic surgery principles used every day in clinical and operative practice. Once completed, the reader should be well equipped to understand more sophisticated concepts conveyed in the literature. The skin is composed of three major tissue layers, the epidermis, dermis and hypodermis, and also of various structures known as appendages. The thick dermis lies beneath this layer and contains most of the skin appendages. The hypodermis lies beneath the dermis and is predominantly composed of adipose tissue. Epidermis the superficial epidermis is composed of keratinised stratified squamous epithelium. The predominant cell type is the keratinocyte, which produces fibrous keratin to provide protective and waterproof functions to this layer. Three other cell types make up this layer: Melanocytes produce melanin which dissipates ultraviolet radiation and aids the production of vitamin D from sunlight; Merkel cells sensory cells associated with light touch discrimination; and Langerhans cells immune surveillance dendritic cells (antigen-presenting cells). Structurally, the epidermis is composed of five distinct layers, each of which has its own cellular make up and function. From deep to superficial they are: Stratum germinativum the actively proliferating basal cell layer, containing melanocytes; Stratum spinosum contains keratinocytes; Stratum granulosum the site of protein synthesis contains mature keratinocytes; Stratum lucidum clear layer present only on the palms and feet; and Stratum corneum contains thick, non-viable keratinised cells, which protect against trauma and sebaceous glands, which produce bactericidal sebum. It is predominantly composed of connective tissue comprising collagen, elastin, ground substance and vascular plexus in a bundled and woven arrangement. Structurally it consists of two layers: P rinci P l es of recons t r u ct iv e s u rgery 5 the superficial papillary dermis, which consists of areolar (loose) connective tissue; and the deep reticular layer, which consists of dense irregular connective tissue. The dermis confers elasticity and flexibility to the skin and at the same time helps it to resist distortion, wrinkling and sagging. The dermis consists predominantly of fibroblasts, collagen and extracellular matrix. It is often considered part of the dermis because it invaginates into it, by attachment via collagen and elastin. Skin appendages Skin appendages are structures derived from the skin that serve particular functions. The appendages are: Hair follicles Sweat glands Eccrine glands Apocrine glands Sebaceous glands. Hair follicles are found in skin covering the entire surface of the body except for the palms, soles and glans penis. Each hair shaft is composed of a medulla, a cortex of keratinocytes and an outer cuticle. The inner root sheath is derived from the epidermis and the outer root sheath from the dermis. The follicles are lined by germinative cells and melanocytes, which produce keratin and pigment, respectively. These muscles function to erect the hair follicles by contracting in the cold or during times of fear and emotion, leading to goose bumps. Eccrine glands are found in the skin covering all body surfaces and secrete an odourless hypotonic fluid under sympathetic control.
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Local infection and fulminant necrotising fasciitis are well documented in liposuction. It is common practice to give one dose of antibiotic pre-operatively and to closely monitor and treat any post-operative fever and cellulitis. A large study of major and lethal complications of liposuction by Lehnhardt et al. Skin necrosis appears to be more common in smokers and in patients who undergo superficial liposuction. They are thought to be more likely if adequate pressure garments have not been used and in patients with a high body mass index. Oedema and ecchymosis are reduced with the use of compression garments for 46 weeks. Occasionally neurological pain may be associated with neuroma formation or damage to underlying fascia or muscle. Mesotherapy involves a series of injections containing multiple ingredients which act in two ways: lipolytic agents stimulate lipolysis and ablative chemicals destroy adipocytes. To achieve a satisfactory outcome, it is paramount that patients adhere to the recommended diet and level of physical activity. Liposuction is under continuous development with regards to technology and instrumentation. It is deemed safe and effective but, as with all invasive surgery, is not without side effects. Diligent patient selection and realistic expectations will give the most rewarding results. Limb contouring after massive weight loss: Functional rather than aesthetic improvement. Intraoperative use of bupivacaine for tumescent liposuction: the Robert Wood Johnson experience. Evidence-based patient safety advisory: Patient selection and procedures in ambulatory surgery. Efficacy of lidocaine for pain control in subcutaneous infiltration during liposuction. Major and lethal complications of liposuction: A review of 72 cases in Germany between 1998 and 2002. The key to long-term success in liposuction: A guide for plastic surgeons and patients. Water-assisted liposuction for body contouring and lipoharvesting: Safety and efficacy in 41 consecutive patients. Advances in liposuction: Five key principles with emphasis on patient safety and outcomes. Globalisation and social media have played a major role in encouraging patients to undergo these procedures (The American Society for Aesthetic Plastic Surgery, 2010). Surgeons therefore have a greater responsibility to appropriately educate patients and use careful patient selection criteria to choose the appropriate candidates for the treatment. While most patients have clearly identifiable concerns and appropriate expectations, care should be taken with patients that are overly expectant and demanding, those requesting multiple interventions. Careful patient selection will avoid disappointment for those who may not have understood the procedure or have underestimated the limitations of surgery. However, key anatomical points relating to facial aesthetic procedures will be emphasised. Soft tissue layer the soft tissue of the face consists of five basic layers which are arranged concentrically (Figure 16. Specific age-related changes occur in each facial layer; procedures to reposition tissues form the basis of facial rejuvenation surgery. Subcutaneous tissue consists of two important components: the subcutaneous fat and retinacular cutis. The retinacular cutis is part of the retaining ligaments that pass through the subcutaneous tissue to provide support. In areas with a thick subcutaneous layer, the retinacular cutis fibres are susceptible to weakening and distension with age. In addition, it forms a key landmark in facial nerve anatomy: below the zygomatic arch, all branches of the facial nerve are deep Bone 3 1) Skin 2 1 2) Subcutaneous 3) Musculo aponeurotic 4) Retaining ligament and space 5) Periosteum and deep fascia 5 4 Figure 16.
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Resumption of sports Confirmation of the full resumption of sports activities depends on the bone consolidation and the restored range of motion. The functional deficits resulting from a posttraumatic loss of maximum power and stamina, muscle imbalances and partial losses of proprioceptive abilities, are not generally evident under everyday conditions. But under the increased demands of sport, they can involve the not inconsiderable risk of further injury. Accordingly, professional, graduated and individually adapted rehabilitation of motor skills in sporting youngsters is useful. This should be based on the nature of the injury, the age of the patient, the practiced sport, the desired level of training 544 4. The fracture- and age-related interaction between 4 Six-monthly check-ups should be arranged for up to two years after the trauma in order to detect any changes in length or axial alignment. This does not apply however to fractures without any risk of a growth disorder. If a growth disorder is already present, the control should continue until the end of growth. Deformities the abnormal position at consolidation, spontaneous correction potential and any growth disorder will determine the bone shape on completion of growth. Possible causes are consolidation in an abnormal position, secondary deformities caused by growth disorders or a combination of these. The configuration of the affected extremity in terms of length, axes and rotation is described in comparison with the unaffected side. After vertebral fractures, the function and statics of the spinal column must be established clinically in three dimensions. Frontal plane: Shoulder and pelvic tilts, lateral deviations of the spinal column, abnormal vertical alignment, waist triangles. Sagittal plane: Profile (kyphoses and lordoses), abnormal vertical alignment, finger-floor distance, segmental mobility. Mobility the abnormal position at consolidation can primarily be influenced therapeutically. The term deformity, on the other hand, describes persistent axial and torsional defects that cannot be compensated for functionally and/or which the patient feels to be unsightly . Remodeling cannot be influenced therapeutically (the administration of hormones and other drugs or foods do not have any detectable effect). On the other hand, an awareness of the limits of spontaneous correction of abnormal positions will enable the remodeling to be anticipated and integrated in the therapeutic strategy in a targeted manner. Deformities that result from inadequate remodeling should therefore be viewed as iatrogenic. Growth disorders can be prevented or therapeutically influenced only to a limited extent. Spontaneous corrections Joint mobility is checked at the earliest 24 weeks after cast or metal removal and documented for both the affected and healthy sides by means of the zero-crossing method/ neutral-zero method (Chapter 2. The subsequent follow-up intervals depend on the site and extent of the deficit and the subjectively experienced functional restriction, which should be queried in detail, and documented, in relation to everyday and sporting activities. Neurological disorders A fundamental philosophical aspect of effective therapeutic strategies is the integration of the corrective growth potential as the fourth dimension of pediatric traumatology. The exploitation of the spontaneous correction of deformities is linked to the following basic principles: Peripheral neuropathies are common particularly after elbow fractures. In most cases, these involve a prognostically benign neurapraxia that recovers completely within a few weeks or months. Clinical assessment and documentation of the sensory and motor nerve functions in the emergency room and subsequently during outpatient check-ups is essential since it allows any iatrogenic causes to be identified and the course of the condition to be monitored. Even age-related or pain-related unreliable findings should be documented as such. If no recovery is apparent by four weeks after the trauma, the patient should be referred to a neurologist for examination and the determination of nerve conduction rates. Sufficient residual growth: the remodeling potential is at its peak before the age of 10 and then declines until the onset of physiological physeal closure.
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In muscular dystrophy patients in particular, the equinus foot represents a key stabilizing component in standing and walking. The slight equinus foot position locks the upper part of the ankle and prevents dorsiflexion. This indirectly extends the knee and the patient is able to hold himself upright passively. Neither orthotic treatment nor surgery is indicated to correct this equinus deformity. On the contrary, the ankles must be stabilized with an orthosis if any free dorsiflexion is present. This brace must be prepared with a slight backward lean in order to stabilize the knee indirectly and thus achieve the same effect as a slight equinus position. In the backward lean position, an extension moment acts on the knee to stabilizes the joint in extension. A powerful triceps muscle or a marginal or slight equinus foot is invariably helpful as these can lock the lower leg in relation to the foot and prevent forward movement, thereby helping to produce the indirect extension moment. Severe equinus deformities, however, require correction but only to -5° to 0° of dorsiflexion. A slight hyperextension of the knee of up to 5° is acceptable, whereas a more pronounced hyperextension can overstretch the knee capsule and lead to later problems in this joint with pain anteriorly. The hyperextension is best prevented indirectly by corresponding orthotic provision for the lower leg and foot, and the forward or backward lean can be adjusted via the heel height. Supports for stabilizing the knee are difficult to produce and hardly ever produce the desired result. Since patients feel uncomfortable during the day with a high-fitting orthosis, a low-fitting orthosis should always be used if possible. For these reasons, it is not useful to provide excessive treatments, but rather to solve problems as and when they occur. Reimers J (1990) Functional changes in the antagonists after lengthening the agonists in cerebral palsy. Rideau Y (1986) Prophylactic surgery for scoliosis in Duchenne muscular dystrophy. J Pediatr Orthop 10: 43341 moveable knee can protect the knee from hyperextension in the stance phase only during knee movement in the sagittal plane. Clinical examination 3 Occurrence Compared to adults, children rarely suffer from lesions of the menisci and/or ligamentous apparatus of the knee. In fact, it used to be thought that such structures could not be injured at all in children. For a long time, the only known internal knee injury in children was tearing of the ligaments at the cartilaginous attachment (particularly the medial collateral ligament and the anterior cruciate as an eminence avulsion) or a meniscal lesion in an existing (lateral) discoid meniscus (Chapter 3. The growing popularity, in recent years, of sport and training during childhood and early adolescence has been matched by an increasing number of internal knee lesions that did not used to be seen in this age group. This is still a low incidence compared to that during the 3rd and 4th decades of life of 90 per 100,000 inhabitants . If an arthroscopy is routinely performed for a hemarthrosis in a child, a rupture of the anterior cruciate ligament and/or a meniscal lesion will be found, depending on the age group, in 3040% of cases (children) or 5060% of cases (adolescents) [16, 27, 28]. Since internal knee lesions in children are difficult to diagnose purely by clinical examination, arthroscopy is often required to correct the clinical diagnosis [3, 16, 27, 28]. The surgical treatment of intraligamentous ruptures of the anterior cruciate ligament while the epiphyseal plates are still open has become a routine treatment in specialist centers over the past 15 years [3, 8, 19]. In our hospital we have observed and treated around 45 such cases over the past 15 years. Diagnosis Recently traumatized knee History the clinical examination of a recently traumatized knee is painful and should therefore be performed gently. Although we do not test for the meniscus signs in the acutely injured painful knee, the status of the ligamentous apparatus can be clinically assessed to a certain extent even in a painful knee. As well as assessing the extent of movement, the examiner should also note the quality of the end point (whether »firm« or »soft«). It should be borne in mind that the knee ligaments are more lax generally in children than in adults and that an anterior drawer of up to 10 mm can still be normal .
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In axonotmesis the axons are interrupted, although the key structures (myelin sheaths) remain intact. The axons regrow at a rate of 1 mm/day along the key structures from the proximal end. If the latter are interrupted or refixed with staggered alignment, defective innervation results. In everyday clinical practice, however, these terms are not kept strictly separate and in some cases are used as synonyms. Clinical features and diagnosis Sensory and motor function are impaired or completely absent in the area of the affected nerve or nerve roots. The typical areas of skin and muscle supplied by the relevant nerve allow a topical diagnosis to be made (Chapter 2. Sensitivity may be completely absent (anesthetic), reduced (hypesthetic) or even increased (hyperesthetic). The muscle dysfunction can also manifest itself in the form of weakness or complete paresis. The presence of sensation and/or motor function rules out a complete nerve lesion. But if complete lesions are present, only the course of the condition will show whether the neuronal structures are actually interrupted or not. The electromyogram can show fine motor impulses that are not clinically detectable and thus enable a more accurate diagnosis to be made. Treatment and prognosis Measures for nerve lesions are basically curative or palliative. A curative procedure is suturing of the damaged nerve, with or without interposition. The prognosis is better for early than for late interventions and better for the upper limbs than for the lower. On a proximal extremity, a success rate of 8090% can be expected after early reconstruction. The results are not so good for a lower extremity, particularly if the peroneal nerve is involved [1, 6, 10]. Prognostically negative factors in relation to the results after reconstructive operations: proximal lesion, increasing age of the patient, increasing time to the intervention, extension of the lesion, certain nerves. Contractures and movement restrictions in the affected section of the extremity must be prevented so that the muscles can be reused in the optimal manner after any reinnervation. Consequently, physical and/or occupational therapy are indicated during rehabilitation. If severe functional deficits are present, a muscle transfer is a possible palliative measure, but a complete recovery is never possible. But modern microsurgical anastomosis techniques now provide the option of a free muscle transfer in which a power generator is transferred from a remote site (where the deficit does not matter so much) to the desired location. Correct phasic activity of the transferred muscle (this is easier to achieve for a former synergist than for a former antagonist [3, 15]). Skeletal deformities compromise the results of muscle transfers Redirections over which the muscle operates after its transfer are undesirable since the muscle loses some power as a result. After the transfer the muscle should remain under tension even at rest so that it does not have to adapt to any overlength by fiber shortening, as happens after tendon lengthening procedures, with a corresponding loss of power. Scar adhesions can hinder the functioning of the transferred muscle despite ideal preconditions, and are particularly common where a tendon passes through fascia or bone channels. Early mobilization should therefore be attempted subject to adequate stability of the reinsertion. The gain in function must compensate for the loss at the site of origin of the transferred muscle. Another therapeutic option involves the optimal adjustment of the existing active range of motion for everyday functions. In addition to functional motor deficits, sensory deficits can also remain, but these are usually tolerated by the patient.
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Cardiac surgery has been undertaken using preoperative iron and recombinant erythropoietin, pre- and perioperative autologous transfusion, and postoperative iron therapy (Yamagishi et al 1998). Folic acid should be given, infections prevented, and the haemolytic state monitored if the patient has her spleen. Weinstein R, Martinez R, Hassoun H, Palek J 1997 Does a patient with hereditary spherocytosis qualify for preoperative autologous blood donation? Yamagishi I, Sakurada T,Abe T 1998 Cardiac surgery using only autologous blood for a patient with hereditary spherocytosis. Children may present with failure to thrive, although beyond childhood, growth is usually normal. There is a tendency to hypoglycaemia and a variable response to glucagon and epinephrine (adrenaline) (Cox 1968). Metabolic abnormalities such as hypercholesterolaemia and increased serum triglycerides occur, but metabolic acidosis is rare. Prolonged fasting should be avoided and a dextrose infusion should be given during the period of preoperative starvation. Casson H 1975 Anaesthesia for portocaval bypass in patients with metabolic diseases. There is evidence that homocystine may affect the coagulation system and the resistance of endothelium to thrombosis, and that it may interfere with the vasodilator and antithrombotic functions of nitric oxide (Nygard et al 1997). The decrease in cystine, which is an important constituent of the cross linkages in collagen, produces a weakened collagen. There is evidence that vitamin E and ascorbic acid can block the effect of hyperhomocystinaemia, thus suggesting an oxidative mechanism for impairment of endothelial cell function (Nappo et al 1999). Hyperhomocystinaemia has been found to be an independent risk factor in young individuals with vascular disease (Clarke et al 1991). After diagnostic criteria had been determined (peak serum homocystine levels following methionine loading), 123 patients with vascular disease presenting before the age of 55 were compared with 27 normal, matched individuals. Hyperhomocystinaemia was found in 42% with cerebrovascular disease, 28% with peripheral vascular disease, and 30% with coronary artery disease, but was not seen in normal subjects. In 18 of the 23 patients with hyperhomocystinaemia, deficiency of cystathionine beta-synthase deficiency was confirmed. Plasma total homocystine levels were found to be a strong predictor of mortality in patients with angiographically confirmed coronary artery disease (Nygard et al 1997). Homocystinuria One of the aminoacidurias, this autosomal recessive, metabolic disease results from a deficiency of cystathionine B synthetase, which H Homocystinuria 248 Medical disorders and anaesthetic problems 2. Homocystine, which is not normally present in the urine, occurs in large amounts, as does methionine. The irritant effect on the vascular endothelium causes platelet aggregation and subsequent thromboembolism. If untreated, 50% of patients have major thromboembolic episodes, and the mortality is about 20% before the age of 30 years (Nygard et al 1997). Treatment consists of a diet that is low in methionine but contains cystine supplements. Pyridoxine, dipyramidole and acetyl salicylic acid may be used to decrease platelet adhesion. Cerebral infarction, which occurred 11 days after Caesarean section, was the presenting feature in a heterozygote (Minkhorst et al 1991). Penetration of a large epidural blood vessel might initiate thrombosis, as may the accompanying venous stasis of the lower limbs. Anaesthesia for lensectomy is most frequently reported (Grover et al 1979, Parris & Quimby 1982, Lowe et al 1995). In a series of 45 patients having 82 operations, the majority required general anaesthesia, and more than half were mentally retarded (Harrison et al 1998). It was postulated that the glutamate agonist effects of methionine, homocystine and cystine interfered with cerebral glutamatergic transmission (Eschweiler et al 1997). Another patient presented with an acute psychiatric disorder that responded to pyridoxine 400 mg daily (Li & Stewart 1999). There are increased risks in pregnancy and maternal deaths have been reported secondary to thromboses (Minkhorst et al 1991, Constantine & Green 1997).
- Cold agglutination syndrome
- Acquired immune deficiency syndrome
- Macleod Fraser syndrome
- Plague, meningeal
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The bedroom is the most important room to maintain as free of cat allergen as possible. They are found throughout homes, but accumulate in bedding, soft furnishings, and carpet. Drying the bedding in high heat in a dryer is an alternative that may prevent scalding injuries in children from having the water heater temperature raised above 50 C (120 F). Immunotherapy is the treatment of choice for hymenoptera venom sensitivity-in carefully selected patients-to prevent life-threatening allergic reactions. Up to 40% of patients with allergic rhinitis but no history of asthma have abnormal pulmonary function tests in response to exercise compared with 63% of asthmatic children and 7% of control children. If both parents are asthmatic, what is the risk that their child will have asthma? For a child with only one parent with asthma, the risk is estimated to be about 20%. About 50% of childhood asthma develops before the age of 3 years, and nearly all has developed by the age of 7 years. The signs and symptoms of asthma, including chronic cough, may be evident much earlier than the actual diagnosis but may be erroneously attributed to recurrent pneumonia. Which children with wheezing at an early age are likely to develop chronic asthma? Although about one third of children will have an episode of wheezing before they are 1 year old, most (80%) do not develop persistent wheezing after age 3 years. Symptoms, most commonly cough, peak 5 to 10 minutes after the conclusion of exercise and usually resolve within 30 to 60 minutes. This exercise can include jogging on a motor-driven treadmill (15% grade at 3 to 4 mph), riding a stationary bicycle, or running up and down a hallway or around a track in field testing. As further verification of the diagnosis, if the patient has developed a decreased peak flow (and possibly wheezing), two puffs of a b2-agonist should be administered to attempt to reverse the bronchospasm. The main causes of airflow obstruction in acute asthma are airway inflammation, including edema, bronchospasm, and increased mucus production. Chronic inflammation eventually results in airway remodeling, which may not be clinically apparent. If there is a clear association with feedings, consider the possibility of tracheoesophageal fistula. Bronchiolitis obliterans: Chronic wheezing often after adenoviral infection Bronchopulmonary dysplasia: Especially if there has been prolonged oxygen therapy or ventilatory requirement during the neonatal period Ciliary dyskinesia: Especially if recurrent otitis media, sinusitis, or situs inversus is present Congenital malformations: Including tracheobronchial anomalies, tracheomalacia, lung cysts, and mediastinal lesions Cystic fibrosis: If wheezing is recurrent, failure to thrive, chronic diarrhea, or recurrent respiratory infections Congenital cardiac anomalies: Especially lesions with large left-to-right shunts Foreign-body aspiration: If associated with an acute choking episode in an infant older than 6 months Vascular rings, slings, or compression n n n n n n n n 24. Within each category, the presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation. A chest radiograph should be considered for a first-time wheezing patient in the following situations: n Findings on physical examination that may suggest other diagnoses n Marked asymmetry of breath sounds (suggesting a foreign-body aspiration) n Suspected pneumonia n Suspected foreign-body aspiration n Hypoxemia or marked respiratory distress n Older child with no family history of asthma or atopy n Suspected congestive heart failure n History of trauma. What are the usual findings on arterial blood gas sampling during acute asthma attacks? Therefore, hypercapnia is a serious sign that suggests that the child is tiring or becoming severely obstructed. This finding should prompt reevaluation and consideration of admission to a high-acuity unit. For the treatment of exacerbations of asthma, nebulizers are primarily used in children younger than 2 years because of the ease of administration. Magnesium sulfate is a known smooth muscle relaxant most commonly used in the treatment of preeclampsia. In asthmatic patients, when used in conjunction with standard bronchodilators and corticosteroids, magnesium sulfate can provide additional bronchodilation. Its role in acute asthma is unclear, but currently it is most commonly used when severely ill patients have failed to respond to conventional therapy. Caroll W, Lenney W: Drug therapy in the management of acute asthma, Arch Dis Child Educ Pract Ed 92:3p82ep86, 2007. Four categories are listed: intermittent, mild persistent, moderate persistent, and severe persistent. Categorization which is also separately done for 04 years and 12 years, helps to guide therapy (Table 17-2).
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Topiramate is a less potent inducer of hepatic enzymes, and this effect seems to be dose dependent. In monotherapy, doses less than 200mg did not significantly alter the pharmacokinetics of the combined oral contraceptive pill containing 35 micrograms of ethinyloestradiol. Further studies in larger numbers of women are needed to clarify this possible effect. If breakthrough bleeding occurs ethinyloestradiol dosages may need to be increased to 75 or 100 µg or the 50 µg pill may be tricycled (three packets taken continuously, then a four-day break). Breakthrough bleeding occurring in the middle of a cycle of contraceptive use is generally due to a relative oestrogen deficiency and usually taken as a sign of incipient failure of contraception48. However, pregnancy rates (approximately 7% per year) still appear to be lower compared with barrier methods which have a failure rate of between 15 and 20%. Medroxyprogesterone injections may be effective in women with epilepsy, with their elimination being dependent on hepatic blood flow instead of hepatic metabolism, but data proving this are not as yet available. Whether the dose of the morning-after pill should be changed in those on enzymeinducing drugs is unknown. Both valproate and lamotrigine serum levels are reduced when taken alongside the combined oral contraceptive pill, via enhanced glucuronidation. The clinical relevance of the effect on valproate is not certain, but it is clinically significant with lamotrigine (>50% drop in serum levels reported). The increasing evidence base for management has also resulted in expert and national groups forming guidelines to aid management, the majority of women with epilepsy will have a normal pregnancy and delivery, an unchanged seizure frequency and over a 90% chance of a healthy baby. However, considering the prevalence of epilepsy many pregnancies are still at risk for an adverse outcome. Because of this, pregnancies in women with epilepsy are considered high risk and need careful management by both medical and obstetric teams. Preconception Preconception counselling should be available to all women with epilepsy contemplating a pregnancy. While it may not always be appropriate to discuss the many relevant issues (for example in paediatric practice) it should certainly be considered in female adolescents with epilepsy, including those whose care is being transferred from a paediatrician to an adult physician. The fact that the relevant issues have been discussed should always be clearly recorded in the notes. Women with epilepsy of childbearing years do not always recall being given relevant information, hence the need to repeat this regularly. For example, the results of a postal survey of women showed that only between 38 and 48% recalled being given information on contraception, pre-pregnancy planning, folic acid and teratogenicity62. Ideally an organised joint obstetric/neurology pre-conceptual counselling service should be available to allow rapid assessment of women actively contemplating pregnancy and to coordinate care during pregnancy63. At present, given the numbers of neurologists and those other specialists with an interest in epilepsy, this is not always available and waiting times are long. Nevertheless, a re-configuration of clinics and additional resources to allow for this service should be actively considered. During counselling a re-evaluation of the diagnosis and the need for continued antiepileptic medication should take place. The risks and benefits of reducing or changing medication should be fully discussed with each individual patient. As well as major malformations the risk of cognitive and developmental delay should also be discussed. Prior pregnancy outcome may be an important factor to consider during pre-conceptual counselling. Small studies of infants with foetal anticonvulsant syndromes quoted this risk as between 39% and 55%, but more recent studies have estimated the recurrence risk of major malformations as between 15. The genetics of the seizure disorder may also need to be taken into consideration. For example, for autosomal dominant conditions such as tuberous sclerosis there is a 1:2 risk of a child inheriting the condition. Most of the inheritable syndromes that include epilepsy in their phenotype are autosomal recessive and there is therefore a low risk of children developing the condition. The risk of a child developing epilepsy is dependent on the type of seizure disorder and the number of affected relatives. The risk seems to be lower if only the father has epilepsy compared with if only the mother has epilepsy66. Folic acid the prescription of folic acid before conception and at least until the end of the first trimester is recommended in patients taking antiepileptic medication, as it is for all women.
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The celes should therefore be closed immediately after birth or, at the latest, within the first few days of life. If hydrocephalus is also present, a drain must be inserted at an early stage in order to prevent any pressure-related brain damage. The predominant factor in patients with myelomeningocele is usually the flaccid paresis (50%). The other patients show a mixed pattern of spasticity and flaccid paresis of 740 4. The impaired neuromuscular function alters the forces that act on the growing musculoskeletal system, causing secondary deformities to develop. The pareses, combined with the loss of sensory functions in the area of the affected segments, lead to a loss of dynamic stabilization of the individual joints. The resulting dynamic muscle insufficiency explains the high risk of spinal deformities, particularly scolioses, even if malformation is not present. Particular caution is indicated in this context since the mobility of the lumbar spine, which has to be sacrificed during surgical corrections, is needed for numerous everyday activities (even for putting shoes on for example). All patients with paralyses tend to develop skeletal deformities of varying degree that also restrict function. Braces must be used and operations performed in order to create the best possible conditions for the rehabilitation of the patients. The treatment of the individual orthopaedic problems is addressed in the respective chapters for the specific areas of the body. Rehabilitation is designed to promote the agematched development of motor, psychological and social skills. Ideally, patients should be able to perform the same activities as healthy children of the same age. For this reasons, braces are indicated from an early age (from 1 1/2 years) in order to enable the child to stand. Deformities can occur at any time and require correction, particularly if they interfere with function. Parents and patients are often anxious about major operations on the hips or the spine. However, given the therapeutic objective of normal psychomotor development it does not seem a good idea on the basis of this anxiety to forbid children from undertaking activities in order to prevent the development of deformities (in order to prevent a hip dislocation for example), and thus at the same time delay their development. While children must develop at their own pace and this process can only be assisted, but not replaced, by treatment, nowadays skeletal deformities can be corrected, albeit with considerable time and effort. The restriction of motor skills that is present in any case as a result of the myelomeningocele always leads to a focal loss, of varying degree, of other abilities. This extensive range of therapeutic services often means that the patient has to attend special schools. Regular medical check-ups are required, particularly during the years of growth, in order to monitor, inter alia, the orthopaedic situation, the urinary tract and the neurologi- cal system. The patients must be encouraged gradually to take responsibility for themselves, learning how to manage their orthoses on their own or catheterize themselves. Only then will they be able subsequently to lead a normal life with maximum independence. The intensive rehabilitation often interferes with the quality of life of the individual patients and places a great strain on the family and healthcare system. Tests are now available for diagnosing a myelomeningocele at an early stage, within the uterus, on the basis of the investigation of the amniotic fluid [45, 62]. From the orthopaedic standpoint the most relevant issue in children with myelomeningocele is their ability to walk. Whereas patients with thoracic or high lumbar myelomeningoceles are barely able to walk, approx. Authors of various studies have attempted to establish parameters for effectively predicting the subsequent ability to walk. The level of the neurological lesion is just one parameter [2, 8, 19, 58], whereas other parameters allow a better prognosis to be made at a more functional level.
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While this development has genetic and social causes, even exercise-averse children should be encouraged to undertake pleasurable exercise from a young age. A child can never make up for what it has missed in terms of motor development between the ages of 7 and 12. At this age, the brain can learn complex movement sequences in a way that is not possible in later life. There are no successful athletes and no great musicians that did not acquire the crucial motor skills at this age. A less gifted child should not let itself be demotivated by the rivalry of more gifted individuals. The doctor can help by finding appropriate types of exercise for acquiring these skills. We are currently seeing a new phenomenon among the young that used not to occur two decades ago: chronic back pain. Nevertheless, we pediatricians have it much easier than those who have to treat adults as back patients. Three factors rarely need to be considered when it comes to young patients: depression, problems in the workplace or a refusal to work and the poorer recuperative powers of 162 3. Because of pension expectations, doctors treating adults often have to struggle (in vain) against the fact that patients despite their protestations do not actually want to be healthy. It is up to us to persuade them to take responsibility for their own health and do something for themselves, in the form of activity. We should help them to practice exercise in a pleasurable way in this context an appropriate sport is usually better in the long term than years of physiotherapy. How much exercise is needed to remain free of pain depends on the deformity and the associated statics. A decompensated spine requires much stronger muscles than a normally shaped spine. A flat back is also disadvantageous since it can lead to a forward shift in the center of gravity that is difficult to offset. I offer my patients with chronic back pain (in which the pain rather than the deformity is the predominant factor) three options: 1. Live with the pain and find ways of coping with its constant presence (possibly relieve the pain with painkillers). Some select alternative types of treatment as a fourth option: chiropractic, Rolfing, atlas therapy, shiatsu, acupuncture, osteopathy, etc. These are popular treatments because they can produce immediate freedom from pain without patients having to undertake any significant activity themselves. However, the duration of pain relief is usually short and the treatment must be repeated constantly. The secret of these treatments lies in the fact that the spastic muscle groups are relaxed (which could also be achieved with any form of heat). However, since the muscles are not strengthened and the cause of the tension is not eliminated, the pain recurs at the next (slightest) exertion. Ultimately, therefore, there is no way of avoiding the daily cyclical exercising of the muscles. Orthopдde 23: 20027 Hestbaek L, Leboeuf-Yde C, Manniche C (2003) Low back pain: what is the long-term course? Eur Spine J 12: 14965 Leboeuf-Yde C, Kyvik K (1998) At what age does low back pain become a common problem? An overview of the indications for spinal imaging procedures is provided in Table 3. Acute, without trauma Acute, with trauma Acute or chronic, without trauma Thoracic spine Acute, without trauma Acute, with trauma Acute or chronic, without trauma Lumbar spine Acute, without trauma Acute, with trauma Acute or chronic, without trauma Chronic, without trauma Lumbosacral Sacrum/coccyx Radiating pain Local pain Deformity Legs Thigh Cervical spine Cervical spine Thoracic spine Thoracic spine Lumbar spine Lumbar spine Chronic, without trauma With or without trauma Positive neurology Psoas is spared Oblique position at birth Oblique position without muscle contraction Rib prominence <5° Fixed kyphosis Lumbar prominence <5° Tissue anomaly Tentative diagnosis? After 4 weeks Directly Directly After 4 weeks Directly Directly After 4 weeks Directly Directly Directly After 4 weeks Directly Directly No Occasionally Directly Directly Directly What is x-rayed? Overview of indications for physical therapy for back conditions Disorder Spondylolysis/ -olisthesis Indication If symptoms are present (pain) Goal/type of therapy Strengthening of back and abdominal muscles (»muscle corset«). No lordosing exercises Straightening, strengthening of paravertebral muscles, stretching of pectoral and hamstrings Straightening, strengthening of paravertebral muscles Duration While symptoms continue Other measures No P. If the olisthesis progresses or neurological symptoms occur or if the pain fails to respond to treatment, possibly operation.