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Deputy Director, Eastern Virginia Medical School

The availability of the patient and affordability of the drug need to be considered in the choice of drugs. It is the second most common cause of tooth loss and is found universally, irrespective of age, sex, caste, creed or geographic location. It is considered to be a disease of civilized society, related to lifestyle factors, but heredity also plays a role. In the late stages, it causes severe pain, is expensive to treat and leads to loss of precious man-hours. Eating fibrous food and chewing vigorously increases salivation, which helps in digestion as well as improves cleansing of the teeth. The quantity as well as composition, pH, viscosity and buffering capacity of the saliva plays a role in dental caries. Aetiology An interplay of three principal factors is responsible for this multifactorial disease. Microorganisms in the dental plaque ferment carbohydrate foodstuffs, especially the disaccharide sucrose, to produce acids that cause demineralization of inorganic substances and furnish various proteolytic enzymes to cause disintegration of the organic substances of the teeth, the processes involved in the initiation and progression of dental caries. The dental plaque holds the acids produced in close contact with the tooth surfaces and prevents them from contact with the cleansing action of saliva. The total amount consumed as well as the physical form, its oral clearance rate and frequency of consumption are important factors in the aetiology. Vitamins A, D, K, B complex (B6), calcium, phosphorus, fluorine, amino acids such as lysine and fats have an inhibitory effect on dental caries. Availability/access to a health care facility can affect utilization of health care services. This leads to increased food impaction between the teeth and formation of new carious lesions. If the fluoride content of the water is at an optimum concentration, it will also exert an anticaries effect. Tongue cleaning and the use of indigenous agents such as the bark of neem or mango (where toothbrush and paste are unaffordable) should be encouraged. The use of various interdental cleaning aids such as dental floss, interdental brush, water pik, etc. Use of an electronic toothbrush in children and persons with decreased manual dexterity is recommended. Increase the intake of fibrous food to stimulate salivary flow, which is protective against caries. Consume caries-protective foods such as cheese, nuts, raw vegetables, fruits, etc. Xylitol (a sugar substitute)-containing chewing gum, if chewed between meals, produces an anticaries effect by stimulating salivary flow. Regular use of fluoridated toothpaste is proven to reduce the incidence of dental caries by 30%.

Differences in physical maturity and strength are great among high school athletes. Coaches should not expect less mature athletes to do the same volume of work that is demanded from upperclassmen. In addition, there are principles of training that are specific to the throwing events. Rotational Acceleration Both the shot put and the discus throw use the rotation of the body to accelerate the implement to its point of release. Even the conventional glide technique of shot putting uses the rotation of the hips, trunk, shoulders and free arm to drive the shot outward. A coach must understand the mechanics of rotary motion and inertia to properly train his or her athletes. This fact is especially true for the shot put spin technique as well as the discus. Rhythm Rhythm is essential to the proper acceleration of the weighted implement in the throwing events. Just as in the jumps, rhythm provides a framework for the application of power; furthermore, just as dancers are graceful and fluid, so must throwers be too. In the discus, for example, the body moves forward, backward, spins and is airborne all at the same time. Throwers must develop the capacity to sense and control their body positions while moving powerfully. The throwing events require the greatest single exertion of power, yet are completed in the briefest amount of time of any track and field event. Lack of relaxation keeps the athlete from achieving the necessary positions from which to apply power. The Mechanics of Throws the aim of both the shot put and discus throw is to propel the implement as far as possible to land within the designated sector. Quite simply, the distance covered by any projectile is a function of five factors: 1. The height of release is largely limited by the stature of the athlete and may vary only a few inches. The angle of attack is critical to discus throwers, but throwing a "flat" discus (and not a "full moon") is quite easily corrected, even in beginning throwers. And, finally, atmospheric conditions are completely out of the control of the thrower, so that is not as much of a concern as a coaching point. Coaching the throws boils down to understanding how to best optimize the angle and height of release while maximizing the speed of release. As the thrower lands in the middle position, the legs drive forward and up and the hips and torso rotate to the front of the circle. Simultaneously, the throwing arm further accelerates the shot as it pushes away from the body. The spin shot put style adds horizontal rotation at the beginning of the throw in order to create greater velocity at the point of release. In the discus throw, the thrower attempts to perform a long acceleration of the implement by applying rotational and linear horizontal force at the rear of the throwing circle. When the thrower reaches the power position, vertical force is also applied to create an optimum angle of release. As the hips turn to the front, the free arm pulls in to shorten the axis of rotation and the front leg blocks. The final acceleration of the discus results from the pull of the throwing arm through the point of release. The optimum angle of release for the shot put is roughly 40-degrees, depending on the height of the release. For the discus throw, the best angle of release varies between 34- and 40-degrees depending on the wind and height of release. A hollow discus with weight distributed away from the center will hold its spin better and increase the aerodynamic stability of the implement.

Therefore, there is less vascularity in this region, and the potential for healing is diminished as compared with intertrochanteric fractures. The deforming muscle forces on the proximal fragment include abduction by the gluteus, external rotation by the short rotators, and flexion by the psoas. Mechanism of Injury Low-energy mechanisms: Elderly individuals sustain a minor fall in which the fracture occurs through weakened bone (pathologic). High-energy mechanisms: Younger adults with normal bone sustain injuries related to motor vehicle accidents, gunshot wounds, or falls from a height. Pathologic fracture: the subtrochanteric region is also a frequent site for pathologic fractures, accounting for 17% to 35% of all subtrochanteric fractures. Ten percent of higher-energy subtrochanteric fractures result from gunshot injuries. Hip motion is painful, with tenderness to palpation and swelling of the proximal thigh. Because substantial forces are required to produce this fracture pattern in younger patients, associated injuries should be expected and carefully evaluated. Field dressings or splints should be completely removed, with the injury site examined for evidence of soft tissue compromise or open injury. The thigh represents a compartment into which volume loss from hemorrhage may be significant; monitoring for hypovolemic shock should thus be undertaken, with invasive monitoring as necessary. A careful neurovascular examination is important to rule out associated injuries, although neurovascular compromise related to the subtrochanteric fracture is uncommon. Associated injuries should be evaluated, and if suspected, appropriate radiographic studies ordered. A contralateral scanogram is helpful to determine femoral length in highly comminuted fractures. Type I: A: B: Fractures with an intact piriformis fossa: the lesser trochanter is attached to the proximal fragment (Fig 31. Have comminution of the piriformis fossa and lesser trochanter, associated with varying degrees of femoral shaft comminution. This is reserved only for those elderly individuals who are not operative candidates, and for children. Nonoperative treatment generally results in increased morbidity and mortality in adults, as well as in nonunion, delayed union, and malunion with varus angulation, rotational deformity, and shortening. Chapter 31 Subtrochanteric Fractures 405 Operative Operative treatment is indicated in most subtrochanteric fractures. Implants Interlocking Nail First-generation (centromedullary) nails are indicated for subtrochanteric fractures with both trochanters intact. Second-generation nails can also be used for fractures extending into the piriformis fossae; trochanteric types are recommended. With use of an intramedullary nail, one must monitor for the nail exiting posteriorly out of the proximal fragment. One must also monitor for the common malalignment of varus and flexion of the proximal fragment. Distally, anterior perforation can occur due to nail femur radius of curvature mismatch. Ninety-Five-Degree Fixed Angle Device the 95-degree fixed angle plates are best suited for fractures involving both trochanters; an accessory screw can be inserted beneath the fixed angle blade or screw into the calcar to increase proximal fixation. These devices function as a tension band when the posteromedial cortex is restored. Proximal femur precontoured locking plates are a newer alternative to traditional fixed angle plates and screws. One must take care not to devitalize the fracture fragments during fracture reduction and fixation. Bone Grafting Closed reduction techniques have decreased the need for bone grafting because fracture fragments are not devascularized to the same extent as in open reduction. If needed, it should be inserted through the fracture site, usually before plate application. With interlocked nails, loss of fixation is commonly related to failure to lock the device statically, comminution of the entry portal, or use of smaller-diameter nails. The nail tends to fail by fatiguing through the lag screw hole in the nail (Fig 31.

The prevalence rates among younger adults (age group of 40 years and above) are also likely to increase; and the prevalence rates among women will keep pace with those of men across all age groups. They refer to a group of diseases associated with uncontrolled cell growth that can affect normal body functions, often with fatal outcomes. These estimates will, however, change as many of the common risk factors for cancers, such as tobacco and alcohol consumption, continue to become more prevalent in India. Fairly conservative assumptions show that the number of people living with cancers will rise by nearly one-quarter from 2001 to 2016. Nearly 10 lakh new cases of cancer will be diagnosed in 2016, compared to about 800,000 in 2001. The incidence of cancers common to both men and women will also see a sharp increase during this period; nearly 670,000 people are expected to die of cancer in India in 2016. There is, however, increasing realization that conditions such as schizophrenia, mood disorders (bipolar, manic, depressive and persistent mood disorders) and mental retardation can impose a marked disease burden on Indians. It is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, especially tobacco smoke and air pollution-both indoor and outdoor. Although asthma can occur at all ages, in about half of the cases it occurs before the age of 10 years. Blindness Data on the current prevalence and future projections for blindness show that the number of blindness cases is expected to remain more or less the same during the next two decades. The projection, however, is based on extremely optimistic projections on cataract treatment that may not be realized. Oral and dental diseases Available data on the current prevalence and future projections for oral health conditions suggest an increase by 25% over the next decade. These data, together with other evidence presented previously on non-communicable diseases, suggest a major future health policy challenge for India. Unintentional injuries include road traffic injuries, poisoning, drowning, falls, etc. It is estimated that the number of deaths from accidents and injuries in 2005 would range from 730,000 to 985,000, with projections that deaths from injuries will increase by as much as 25% over the next decade. These estimates do not include the health impact of injuries with non-fatal outcomes (including permanent disability), which tend to be heavily underreported in India and could well be in the region of about 5 crore cases per year. Available evidence from India also shows that much of the mortality from injuries due to road traffic accidents, occupational accidents and suicide is concentrated among Disease burden in India: Estimations and causal analysis 5 adults in their peak work ages, i. In most cases, disease occurrence and progression can be avoided or significantly reduced/ contained if access to right information and/or early treatment is assured. In countries such as India where there are limited resources and competing demands, not all conditions can be treated and not every intervention provided at public expense. At some point prioritization of interventions or population groups that need to be supported with public funding becomes inevitable. The issue then arises as to the criteria that ought to be used for identifying such publicly supported interventions. The first ensures that the intervention markedly reduces the burden of disease, and does not simply result in a token improvement in the health status. Thus, policymakers can focus on several extremely cost-beneficial and cost-effective interventions that simultaneously yield large gains in outcomes for several major health conditions. While the probability of death beyond a certain age, say 70 years, tends to be high and is not very dissimilar across developed and developing nations, the largest gains in mortality reduction are likely to be achieved at younger ages. An understanding of why these differences exist at younger ages offers the possibility of identifying cost-effective interventions, particularly among children and younger adults. Similarly, malnutrition makes a child susceptible to diarrhoeal diseases and respiratory infections which, when untreated, can be fatal. Beyond the phase of infancy, immunization becomes critical in warding off potentially fatal conditions. The enormous cross-state variations in immunization rates and the low rates of immunization in several States suggest great potential for reducing the mortality from vaccine-preventable conditions. Similarly, with the likelihood of 18% of all Indians dying before the age of 40 years (Jha and Nguyen 2001; Deolalikar, forthcoming), about 8. Huge gains in mortality reduction among young adults are likely by reducing smoking and tobacco use. Costeffective interventions to address smoking include: ending advertising for cigarettes, beedis and other tobacco products, enhanced taxes on cigarette sales and production, and dissemination of health messages.