Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle.

The bony development of the growing child can lead to a variety of hindfoot and ankle problems. Overuse injuries are common, often occurring in conjunction with symptomatic pes planus and plantar fasciitis. Predisposing structural differences such as Haglund's disease, os trigonum, rigid and flexible pes planus, and Sever's disease merit special attention, but treatment may require only patient education and conservative management. Sprains and fractures of growing joints, however, may have poor outcomes if ignored or missed.

Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot.

Foot problems in children can be the result of infection, trauma or overuse. Ingrown toenails, bunions, sesamoid disease, congenital overriding of the fifth toe, and fractures may occur in both adults and children. Some disorders, such as Freiberg's infarction and Kohler's disease, however, are unique to the pediatric population. The potential for adverse sequelae is greater in children than in adults. A thorough understanding of the anatomy of the pediatric foot and a systematic examination will facilitate the diagnosis of pediatric foot problems. A conservative approach to management will improve both compliance and outcome.

Complications of vasectomy.

Family physicians should be aware of the potential effects and complications of vasectomy so they can appropriately counsel patients seeking sterilization. Vasectomy produces anatomic, hormonal and immunologic changes and, although not substantiated by clinical studies, has been reputed to be associated with atherosclerosis, prostate cancer, testicular cancer and urolithiasis. Complications of vasectomy include overt failure, occasional sperm in the ejaculate, hematoma, bleeding, infection, sperm granuloma, congestive epididymitis, antisperm antibody formation and psychogenic impotence. Compared with tubal ligation, vasectomy has fewer serious complications and a comparable failure rate.

Calcium channel blockers in the treatment of hypertension.

Physicians need to weigh the efficacy, adverse effects and cost of first-line antihypertensive agents. Calcium channel blockers lower blood pressure, improve coronary blood flow and depress cardiac contractility by relaxing smooth muscle and cardiac muscle. They have beneficial or neutral effects in hypertensive patients with angina, asthma, chronic obstructive pulmonary disease, postural hypotension, peripheral vascular disease, depression, sexual dysfunction, diabetes and hyperlipidemia. The major adverse effect of some calcium channel blockers is that they may worsen congestive heart failure in some patients. Because calcium channel blockers are metabolized in the liver, the dosage must be lowered in the elderly and in patients with hepatic disease. Diltiazem, verapamil and nifedipine represent prototypes of the three classes of calcium channel blockers, each with slightly different effects.

Psychiatric implications of tattoos.

Psychiatric disorders, such as antisocial personality disorder, drug or alcohol abuse and borderline personality disorder, are frequently associated with tattoos. Finding a tattoo on physical examination should alert the physician to the possibility of an underlying psychiatric condition.