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By I. Gancka. Patten College.

It offers a means of managing many of the dilemmas patients with chronic pain and addiction present [86 order lozol 2.5 mg, 87] lozol 2.5 mg on-line. None of these have been subjected to controlled clinical trials and can substitute for the casuistry of the independent clinical judgment purchase lozol 2.5 mg amex. Notwithstanding their limita- tions lozol 2.5 mg lowest price, failure to explore generic lozol 2.5 mg line, document and address these risk factors would not meet the standard of care for treating chronic pain patients with addiction [88, 89]. Warning signs [adapted from 88] Mild misuse Increasing dose without permission occasionally1 Occasional loss of prescription Preference for a specific pain formulation Moderate misuse Use of the drug to treat symptoms other than chronic pain2 Use of alcohol or other illicit drugs2 Stockpiling drug1 Occasional request for early refill without purported loss of medication1 Purchasing drugs on the street once or twice1, 2 Seeking prescriptions from other providers or the emergency room infrequently but informing primary clinician1 Complaints of adverse effects with any but preferred pain medication Seeking the psychoactive rather than analgesic effects of medication2 Nonadherence to psychosocial dimensions of pain program Inordinate amount of time and energy spent in assuring adequate supply and dosage of pain medication1 Decline in functioning from pretreatment baseline Severe misuses Injecting oral formulations Stealing drugs Forging prescriptions Continual escalation of dosage Diversion of medications Consistent pattern of purchasing drugs on the street Seeking prescriptions from other providers or the emergency room frequently Either hiding behavior or lying to primary clinician about sources and frequency of obtaining medications from other sources Refusal to participate in any psychosocial aspects of pain program Refusing addiction treatment Dysfunctional behavior or gross decline in functioning in multiple spheres of life 1 Behaviors that may also be associated with pseudoaddiction. Researchers disagree on the classification, significance and gravity of the var- ious factors, particularly those on the less pathological end of the spectrum. Table 3 lists some of the most common factors according to whether they rep- resent mild, moderate or severe misuse of controlled substances. Mild misuse is an occasional patient-initiated adjustment in prescribed regimen; moderate misuse is a more frequent and severe misuse of prescriptions contrary to the physician’s intentions and instructions; pathological use involves exploitation of the physician and often criminal behavior. The frequency, To Help and Not to Harm 165 contextual features, intentionality of the patient, and severity of the factors must all be considered when formulating an appropriate therapeutic response to problematic behavior. In every situation in which a problematic behavior emerges such as esca- lating the dose of medication without permission, consider how best to use the behavior therapeutically. Were they afraid that if they told the physician they were in pain, he would think they were addicted and further reduce or stop the medication altogether or were they seeking additional relief from anxiety? In the first case reassurance should be the response and a readjustment of dose, in the second the patient may require assessment and treatment of an anxiety disorder as well a substance abuse. Patients with drug misuse or even abuse may respond to an increase in visits, closer monitoring with urine drug screens, pain diary, psychi- atric assessment, tighter control of medication supplies or other strategies. Pseudoaddictive behaviors or those associated with other mental illnesses will usually respond to the appropriate pharmacological and psychosocial therapy, while true addiction will continue to escalate and declare itself with an ever more exploitative and dangerous pattern. Even when a patient’s behavior necessitates curtailment of narcotics for the protection of patient and community, providers must not abandon patients but continue to offer health maintenance and preven- tion and therapy for the many medical consequences of substance use. If you’d like more information about this book, its author, or related books and websites, please click here. PAIN MEDICINE AND MANAGEMENT Just the Facts Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the con- traindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Wallace, MD Program Director Center for Pain and Palliative Medicine University of California, San Diego La Jolla, California Peter S. Staats, MD, MBA Associate Professor, Division of Pain Medicine Department of Anesthesiology and Critical Care Medicine and Department of Oncology Johns Hopkins University Baltimore, Maryland McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2005 by The McGraw-Hill Companies, Inc. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. For more information, please contact George Hoare, Special Sales, at george_hoare@mcgraw-hill. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent.

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From toddler to adolescence 54 Legg–Calve´–Perthes disease The patient with Legg–Calve–Perthes disease´ presents with a limp generic 2.5mg lozol visa, usually of the antalgic or painful type safe 2.5mg lozol, and commonly made worse with activities cheap 2.5 mg lozol amex. The limp generally reflects hip irritation or synovitis and very importantly is not directly related to the degree of radiographic changes evident in the femoral head 1.5 mg lozol amex. If Legg–Calve–Perthes disease is verified´ on the radiographs the leg is usually shorter discount lozol 1.5 mg amex, and there may be some thigh atrophy as a reflection of disuse, secondary to discomfort. Not uncommonly the hip will be restricted in its range of motion, particularly in hip abduction and internal rotation. All children exhibiting signs of hip irritation demand radiographic evaluation. Plain radiographs are (a) capable of establishing a diagnosis in well over 95 percent of all cases. Only occasionally has radionuclide imaging been found necessary when clear-cut radiographic changes were not evident. The most commonly seen changes in association with Legg–Calve–Perthes disease´ are a widening of the medial joint space, a subchondral crescent sign (or subchondral fracture) seen in the weight bearing anterosuperior and lateral aspect of the femoral head, irregular changes in the density of the head, fragmentation of the ossified portion of the head, a vertical reduction in height of the epiphysis, and not uncommonly, a lateral extrusion of the femoral head from the confines of the acetabulum (Figures 4. The diagnosis is therefore suspected clinically and established radiographically. Anteroposterior (a) and lateral (b) radiographs demonstrating fascinating is strikingly crystallized in the early Legg–Calv´e–Perthes disease with total head involvement. Over´ 20 times the number of English-speaking articles on this condition have been published for every article on transient synovitis of the hip. This is a clear paradox of interest, since the physician will likely encounter cases of 55 Legg–Calve´–Perthes disease transient synovitis of the hip at least four to five times more commonly. Although we have learned a great deal about the natural history of treated and untreated Legg–Calve–Perthes disease, we have added´ little of significance to our understanding of the basic etiology since 1907 when Legg in Boston, Calve in France, and Perthes in´ Germany gained the honor of the original descriptions. Legg, in fact, suggested that he was unsure that treatment would ever affect the natural history of this disease, and now over 90 years later, we have improved our overall results with treatment only moderately (20 to 30 percent improved radiographic results). Legg–Calv´e–Perthes disease with total head involvement and understanding, the overwhelming body of more advanced changes of femoral head fragmentation. It is likely that the radiographic hip changes merely reflect the capital femoral epiphysis’ susceptibility and fragility to unknown insults to its blood supply. Nearly 90 percent of the cases show retardation of the bone age of a significant nature. Anteroposterior radiograph demonstrating advanced stage of common pathway of the unknown etiologic femoral head deformity secondary to Legg–Calv´e–Perthes disease. Biopsies have substantiated that while cellular death of the epiphysis is always present; there is always demonstrable healing, with reparative bone occurring simultaneously, to a greater or lesser degree. This biologic ingrowth of revascularized tissue prevents the actual loss of bone substance seen so commonly in elderly people with avascular necrosis. The femoral head always recovers, and although it may substantially deform, it does not disappear. The evolutionary end result of this “death and healing” process is a femoral head that is relatively spherical (normal) or deformed in degrees, with the worst result being a flattened expanded head with a short squat femoral From toddler to adolescence 56 neck, and a high-riding greater trochanter. Three basic radiographic patterns have been described to characterize the end result hip: spherical congruity (a round ball with a round socket); aspherical congruity (a deformed ball with an accommodating deformed socket); and aspherical incongruity (a squared flat type ball with a round socket) (Figure 4. It has been shown that aspherical incongruity will most regularly result in the greatest number of cases with premature arthritis requiring total hip replacement or other reconstructive surgery in the future. Once the femoral head begins to extrude outside the confines of the outer ledge of the acetabulum, and if the healing process within the head is incomplete, the head will continue to deform (flatten) and permanently become Figure 4. Treatment is designed to intercede and arrest this “extrusion” process, as mild degrees of deformity are often seen to reshape and remodel, and often retain a spherical contour. From the patient’s standpoint the basic issue is rather simple: is premature arthritis likely to occur, and can any form of treatment prevent it? Currently most orthopedic surgeons have embraced the concept of “containment. Consequently most currently popular forms of treatment seek to achieve, by one technique or another, containment of the head within the socket.

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They should be excised one at a time to prevent massive blood loss order 2.5 mg lozol with mastercard, and excision should proceed from top to bottom and from medial to lateral purchase lozol 2.5 mg on line. Burns are excised with the Goulian dermatome with the 10 or 12:1000 inch guards cheap 1.5mg lozol fast delivery. Serial passes of the dermatome are performed until living tissues are reached and all skin appendages have been removed cheap lozol 2.5mg. If they are left behind generic 2.5mg lozol with mastercard, some re-epithelialization may occur underneath the skin graft, leading to graft loss and poor esthetic outcome. When excision of forehead burns is considered, the eyebrows should be spared to allow conservative healing and regrowth of hair follicles. Serial excision per- formed in an orderly fashion helps to prevent massive blood loss. Simultaneous excision of two or more areas at any given time should be avoided and condemned. This leads to massive bleeding, poor control of plane of excision, and hemody- namic instability. Active bleeders are controlled with bipolar cautery, followed by the application of epinephrine-soaked (1:10,000) Telfa dressings. Therefore extreme care must be taken to keep the epinephrine from running onto unexcised areas, which would lead to spasm, congestion, and overex- 286 Barret FIGURE 3 Total face excision in a patient with full-thickness burn. Telfa dressings are left in place for 10 min to allow enough vasoconstriction. The blood clot is then wiped out with the same dressing and the zone is inspected for acute bleeders, which are controlled with bipolar cautery. Any remaining capillary bleeding is controlled with serial applications of epineph- rine-soaked Telfa dressings left in place for another 7 min. The area can also be sprayed with topical fibrin glue, which provides excellent hemostasis and good graft take. Wound closure Following excision and appropriate hemostasis, each area is covered with homo- grafts, placed in similar fashion to autografts. The grafts are tailored to match The Face 287 esthetic units, with graft seams placed in the boundaries of units. Homografts can be secured with staples in the large flat areas, whereas sutures should be used for the eyelids, nose, and lips. They do vascularize in the presence of viable tissue, and this unique property makes them the temporary cover of choice. Xenografts and Biobrane can be used in a similar fashion, but they do not integrate in the wound and therefore tissue viability is not tested. Graft seams are moistened with bacitracin or chlorampheni- col ointments and graft surfaces kept moist with petroleum jelly or polysporin ointment. Oral intake is allowed, but wounds should be kept clean to avoid any graft shearing and infection. Stage Two: Second Look and Autografting Approximately 1 weeklater (between 4 and 7 days after excision and homograft- ing), the patient returns to the operating room for definitive wound closure. If homo- grafts are well adherent to the wound bed and there are signs of revasularization, the wound is ready for skin autografting. When the homografts are found to be loose and nonadherent, facial wounds need to be excised and homografted again. In this case, patients return 4 days following the second stage for a further inspec- tion. If the wound bed is vital, epinephrine-soaked (1:10,000) Telfa dressings are applied. When grafts need to match nonburned or healed face areas, the scalp should be used. When the entire face must be grafted, the scalp does not provide enough quantity of skin graft. The skin grafts must be obtained from the same donor site to graft the entire face with the same quality of skin to render a good color match all over the face. It is not acceptable to obtain skin from the scalp and elsewhere at the same time. This will inevitably leave an area of color mis- match that will be not accepted by the patient. When the scalp is used, the size and form of the skin grafts should be drawn on the surface before any subcutane- ous infusion is applied.

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Gerstenbluth RE generic lozol 1.5mg without prescription, Spirnak JP buy lozol 2.5mg lowest price, Elder JS: Sports participation and using protective eyewear discount 2.5 mg lozol amex, participating in sports high grade renal injuries in children generic lozol 1.5 mg with visa. McAleer IM cheap lozol 2.5mg on-line, Kaplan GW, Lo Sasso BE: Renal and testis injuries BASICS OF THE EYE EXAMINATION in team sports. Nattiv A, Puffer JC, Green GA: Lifestyle and health risks of col- HISTORY legiate athletes: A multi-center study. Sagalowsky AI, Peters PC: Genitourinary Trauma, in Walsh PC, The history should include a detailed description of Retik, AB, Vaughan ED, Jr, et al (eds. It is also crit- EPIDEMIOLOGY ical to perform a thorough examination, and not solely focus on the obvious area of involvement. CHAPTER 28 OPHTHALMOLOGY 163 Pupils: Using a bright light source, check to ensure Lacerations suspected of involving the lacrimal pupils are round, symmetric, and reactive. Conjunctiva and sclera: Here pay close attention One of the most common sports-related eye injuries for signs that suggest a ruptured globe, including (Zagelbaum, 1997), accounting for 33% of all eye lacerations, 360° subconjuctival hemorrhage, or injuries seen in Major League Baseball and 12% of extruding pigment (uveal tissue) or gel (vitreous these seen in the National Basketball Association humor). Cornea: Assess for clarity, then apply fluorescein to identify epithelial defects or foreign bodies. Anterior chamber: Ensure the chamber is well- Sharp pain, photophobia, foreign body sensation, and formed, comparing to unaffected side. EXAMINATION Fundoscopic examination: This should be performed Check visual acuity. Then apply fluorescein stain, in all cases of eye trauma, paying special attention to preferably with topical anesthetic and assess using a the red reflex. The pain should improve with the subtle clue to the presence of significant pathology. Any epithelial staining confirms Other: Although slit-lamp examination is ideal for all the diagnosis. As Flip upper and lower lid to search for foreign body, if such, it is often deferred for more serious cases that suspected from mechanism. TREATMENT Apply topical broad-spectrum antibiotic and follow COMMON EYE INJURIES daily until epithelial defect resolved. EYELID LACERATIONS For patients with significant photophobia, prescribe 1% cyclopentolate tid for 2–3 days. SYMPTOMS CORNEAL/CONJUNCTIVAL LACERATIONS Localized pain and bleeding around the eye SYMPTOMS EXAMINATION Mild pain and foreign body sensation for conjunctival Check for involvement of the lid margin. TREATMENT Perform complete eye examination, especially look- Clean area with betadine and inject lidocaine for local ing for scleral laceration, other evidence for ruptured anesthesia. Then explore wound for foreign body, irri- globe, or a conjunctival foreign body. Remove suture a flat AC, irregularities of the iris, or fold in the in 7–10 days. SUBCONJUNCTIVAL HEMORRHAGE RETINAL DETACHMENT Very common finding after blunt trauma. EXAMINATION Ask about “flashing lights” or new “floaters,” as often Mainly assess for foreign body and ensure no rup- dismissed by the patient. Check Urgent ophthalmology referral only if extensive hem- for afferent pupillary defect (present with larger orrhage (nearly 360o around the cornea). HYPHEMA TREATMENT Bleeding into the AC that can occur after any type of Urgent ophthalmologic consultation for dilated fundo- significant blunt trauma. Laser treatment for certain retinal tears or holes, while surgery for detachments. Blurry vision if larger RUPTURED GLOBE/PENETRATING INJURIES hyphema or associated traumatic iritis. More Perform complete eye examination, including intraoc- common among myopic athletes. With slit lamp, can see actual red cells floating, Vary with area of involvement. TREATMENT Obtain ophthalmologic consultation, as many will EXAMINATION admit for observation. Emphasize strict bed rest, ele- Athorough eye examination is important, but do not vate head of bed to 30o, and eyeshield at all times to apply pressure to the globe.

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The volume stresses the importance of sound methodologies generic lozol 1.5 mg fast delivery, and presents philosophical arguments against randomized controlled clinical trials (e buy 1.5mg lozol overnight delivery. Nonetheless purchase 1.5 mg lozol fast delivery, the question of whether pla- cebo effects can operate (under at least some circumstances) in these populations has not been investigated adequately buy lozol 1.5 mg without a prescription. There is recognition that researchers should never exceed the research participant’s tolerance limit in any type of investigation (whether it is of experimentally induced pain or pain that results from disease) generic lozol 2.5 mg free shipping. Factors such as the need for ethics review, avoidance of conflict of interest, and knowledge of intricacies involved in both quantitative and qualitative research methodologies (e. Sternbach (1983) suggested that at- tention needs to be paid to recruiting the smallest possible number of par- ticipants, using the least intense stimulation and the shortest possible pain duration. It is also important to advise participants of any and all risks in- volved in the study. Although both Fields (1995) and the declaration of Helsinki (WMA, 1964/ 2000) raise strong objections to the use of placebos in the study of condi- tions for which alternative effective therapeutic methods are available, there may still be compelling scientific reasons to include placebos. For in- stance, a psychologist could make a valid scientific argument concerning the need to study the placebo response itself. Such a situation could raise very difficult issues for the researchers, research ethics boards, and organi- zations that adopt ethical guidelines concerning placebos. Nonetheless, the welfare, well-being, and dignity of the research participants should always be given the highest priority in decision making. The possible need to study the placebo response itself has not been directly addressed by the various ethical guidelines discussed here. Nonetheless, under ideal circumstances, researchers interested in studying the placebo response would do so within the context of larger studies that involve trials of new treatments for conditions for which effective interventions are not available. Related to the IASP curriculum, one of the most fundamental ethical is- sues for psychologists working in the area of pain is that of competence. Competence is most directly linked to ethical principles relating to caring 336 HADJISTAVROPOULOS for others, as a lack of competence can have detrimental consequences for clients. The evaluation of a psychologist’s comprehension of ethical issues should include the important determination of whether he or she is practic- ing within his or her area of competence. The expectations outlined in the IASP psychologists’ curriculum include knowledge/understanding of noci- ceptive mechanisms, experimental and clinical pain measurement, psycho- logical impact of different types of pain, psychological and behavioral as- sessments of individuals with pain, psychosocial impact of pain, pain syndromes particularly influenced by sex and gender, life span issues, health care seeking, economic and occupational impact of pain-associated disability, psychological and psychiatric treatment, pharmacological and in- vasive pain management procedures, interdisciplinary treatment programs, prevention and early intervention, treatment outcome and evaluation, and ethical standards and guidelines. In addition to familiarity with these topi- cal areas, adequate supervised clinical and/or research experience is nec- essary to achieve an adequate level of competence. Finally, it is increas- ingly being suggested that psychologists should be utilizing empirically supported interventions (see Chambless & Hollon, 1998) when working with clients (e. APS Guidelines The American Pain Society (APS) also adopted its own code of ethics (APS, 1996–2001). Its standards and principles address human and animal re- search as well as clinical practice. With respect to pain-related clinical research, the APS guidelines endorse the principles of a variety of organiza- tions including the World Health Organization and the American Psycholog- ical Association. Much like the IASP document, the APS standards stress the need for thorough and impartial ethics review, informed consent (or con- sent from a proxy legally responsible for the research participant), not us- ing in pain research persons who are incapable of providing consent (e. With respect to pain-related clinical practice, the APS document stresses that the principles of medical ethics published by the American Medical As- sociation should apply to all clinical disciplines engaged in pain therapy and stress the importance of dedication to competent service with compas- sion and dignity, honesty, respect for the law, respect for the rights of oth- ers, continuation of research, application and dissemination of knowledge 12. It also stresses that profession- als can choose “whom to serve” except in emergencies, and recognizes the responsibility of participating in the activities of a free community. Many psychologists might criticize some of the standards put forth by the APS for pain-related clinical practice. For example, the APS document states, “A health care provider shall be dedicated to providing competent medical service with compassion, respect and dignity” (p. Because psychologists provide psychological and not medical services, one could argue that the standard is not stated sufficiently broadly for their purposes. Moreover, an argument can be made that another standard (“A health care provider, in the provision of appropriate patient care, except in emergencies, shall be free to choose whom to serve, with whom to associate, and the environ- ment in which to provide health-care services,” p. That is, it can be argued that the standard can serve, in some peo- ple’s minds, as justification for refusing treatment on grounds such as eth- nicity and sexual orientation. Although such discrimination does not occur often in clinical settings, it would be important to emphasize within the standards that any refusal of service should be done only with adequate justification and in a manner that shows respect for the dignity of all per- sons.

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