By B. Vasco. University of Arkansas at Pine Bluff. 2018.

The extent of this osteolysis has prognostic require different treatment generic zebeta 5 mg overnight delivery. We do not consider other imaging procedures Epiphyseal dysplasia is a disorder of the bony structure of to be useful in the initial stages generic zebeta 10 mg without prescription. It is a hereditary condition that occurs in two forms: as multiple epiphyseal dysplasia and as spon- A case of Legg-Calvé-Perthes disease can be diagnosed dyloepiphyseal dysplasia (with involvement of the spine; several weeks earlier with bone or MRI scans than with chapter 3 purchase zebeta 5 mg visa. The femoral head findings can appear conventional radiographs (the latter especially in combi- very similar to those in Legg-Calvé-Perthes disease effective zebeta 5mg. However cheap 10mg zebeta otc, since the early The following are diagnostic indications of epiphyseal diagnosis does not have any therapeutic consequences the dysplasia: costs of these imaging procedures can safely be avoided. The following are more typical of Legg-Calvé-Perthes disease: ▬ unilateral involvement, ▬ if bilateral involvement is present: pronounced asym- metry, disease in differing stages, poss. X-ray of 5-year old boy in the early stage of Legg-Calvé- Perthes disease: Note the widening of the joint space (visible par- ticularly over Koehler’s radiographic teardrop) and the slight flattening Sometimes it is not possible to make a clear distinction and condensation of the femoral head compared to the healthy side between the two diseases. Ultrasound scan showing protrusion of the right femoral head in Legg-Calvé-Perthes disease (compared to the left side) 208 3. Inflammatory disorders The distinction is important as the mid-term prognosis! Septic arthritis of the hip almost always results in for epiphyseal dysplasia is much better than for Legg- femoral head necrosis if it is not treated adequately Calvé-Perthes disease. In be more reserved in deciding whether therapeutic mea- contrast with Legg-Calvé-Perthes disease, however, sures are indicated. Treatment is almost never required for cartilaginous damage with narrowing of the joint epiphyseal dysplasia. Other disorders associated with Legg-Calvé-Perthes disease Trauma Avascular necrosis of the femoral head similar to that in Posttraumatic femoral head necrosis can occur at any age, Legg-Calvé-Perthes disease occurs with increased fre- and particularly after femoral neck fractures, although quency in the following illnesses: we have also experienced cases in which this complica- ▬ sickle cell anemia, tion has occurred after an avulsion fracture of the greater ▬ thalassemia is associated with an extremely high inci- trochanter (as a result of tearing of the circumflex femoral dence (25%) of avascular femoral head necrosis, artery). The unambiguous history makes the differential ▬ trichorhinophalangeal syndrome, diagnosis very easy in such cases. This can affect up to ▬ hemophilia (the incidence in hemophilia is 7% 5% of patients with leukemia. Fortunately, we have), not encountered the alcohol-induced form, which fre- ▬ congenital tibial pseudarthrosis. Since the prognosis for the avascular necrosis that occurs Treatment in the above disorders is no different from that of Legg- Calvé-Perthes disease, it is treated according to the same The therapeutic measures for Legg-Calvé-Perthes guidelines. No reliable findings exist on the options for the drug-in- Tumors duced improvement of the circulation in the femoral head. An important differential diagnosis in relation to Legg- Calvé-Perthes disease is a chondroblastoma ( Chap- Improved mobility ter 3. The efficacy of measures for improving the mobility of This tumor occurs predominantly in children. The primarily restricted movement is abduction, blastoma, however, the height of the femoral head is not while internal rotation may also be diminished. Moreover, ability to abduct is particularly impaired in the pres- the presence of non-load-related pain should indicate the ence of lateral calcification and increasing subluxation. If the femoral head loses the ability to slide smoothly Metaphyseal tumors or cysts can occur secondarily in the acetabulum, a hinge abduction can develop. Preserving mobility is an extremely important therapeu- tic objective in Legg-Calvé-Perthes disease. As soon as a restriction occurs, regular physiotherapy should be initi- ated as this measure is generally sufficient for preserving adequate mobility. In some cases, the physiotherapy will need to be continued for several years. Pretreatment prior to osteotomy in cases of poor mobility: Hydraulic mobilization of the hips under anesthesia, Petrie cast in The preservation of mobility is also the basic require- maximum abduction, physical therapy under epidural anesthesia ment for measures designed to improve containment. If a hinge joint has already formed, then an intertrochanteric varization or pelvic osteotomy is not indicated. In many However, the surgeon can attempt to improve the situa- cases, however, appropriate mobilizing measures can re- tion with a resection of the laterally developing protrusion store joint mobility to some extent.

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Although practices such as testing for all relationships between all variables (so called “data-dredging”) are unscientific cheap zebeta 10 mg, it is acceptable to make economical use of data that have been expensive to collect and that are appropriate for answering new questions generic zebeta 10mg online. The first paper reported the development of a new questionnaire to measure the prevalence of chronic zebeta 5 mg with mastercard, persistent cough in epidemiological studies of children discount 10 mg zebeta mastercard. The second and third papers report data from studies in which the questionnaire was used purchase zebeta 10mg amex. The second paper was used to report evidence that children with symptoms of persistent cough do not have the same clinical features as children with clinically recognised asthma. Finally, in the third paper, the prevalence and risk factors for asthma and allergic illness in the two different countries was compared. Each paper has a clear, individual message and avoids the duplicate publication of data in the other papers. This process makes sense because the results reported in the three papers answer discrete questions and could not have been compressed into the constraints of a single paper. Because it was unlikely that one journal would have taken all three papers, each journal was chosen because the paper fell within its scope. Measuring persistent cough in epidemiological studies: development of a questionnaire and assessment of prevalence in two countries. Prevalence of atopy, asthma symptoms and diagnosis, and the management of asthma: comparison of an affluent and a non-affluent country. Policies for data sharing Premature release of research data before careful analysis of results, and without the independent scientific peer review that is part of the normal process of publication of scientific research, would also increase the risk of public disclosure of erroneous or misleading conclusions and confuse the public. In many large research studies from which more than one paper will be published, strict policies are needed for data sharing to avoid duplicate publication and to specify each researcher’s rights and responsibilities. It is the duty of the stakeholders in these studies to make collective deci- sions, in advance, about many aspects of publication. The stakeholders will include the principal investigators and other researchers, such as the divisional or departmental head, the project coordinator, the data manager, the research assistants, research fellows, postdoctoral students, and/or a statisti- cian, etc. The decisions will include which questions will be answered, which dependent and independent variables will be used, which journals to select for publication, which national or international meetings the data will be presented at, and who will write the paper and present the data. One good way to handle data sharing is to create a log sheet for each proposed paper. The log sheets should be formal documents that are agreed to by all stakeholders and that are formally archived in the study handbook. Once the questions to be answered in the paper are finalised and the log sheet has been approved by the stakeholders, data sharing becomes plain sailing. In a perfect world, data sharing log sheets would be used routinely in all research studies. Conferences where data will be presented and by whom 151 Scientific Writing This level of organisation often makes the difference between an everyday research team and a highly successful research team. As discussed in Chapter 2, the first author must take full responsibility for preparing the paper. This author will be responsible for supervising or conducting the data analyses, documenting the results, and preparing the drafts of the paper, abstracts, posters, etc. The first author should also have the first option of presenting the results at scientific meetings. However, all stakeholders should have access to results for use in reviews, talks, research reports, etc. When data are used by other stakeholders in this way, the first author should be acknowledged accordingly. Data sharing has the potential to cause many emotional and professional conflicts. For this reason, academic departments and research teams need to work collaboratively to form their own data sharing policies in a consensus forum. Such policies need to be approved by the divisional or departmental head and/or other people who have the responsibility of administering research policies and mediating any problems that occur. Only the adoption of a sensible and collaborative management approach can ensure that the issues of intellectual property, data sharing, and authorship are handled in a way that is rewarding for all of the parties involved. Fast tracking and early releases In science read, by preference, the newest works; in literature, the oldest. Edward Bulwer-Lytton (1803–1873) If you think that your results are exciting and important and that they need to be published quickly, it is sometimes possible to queue-jump and expedite publication. If you feel that your work needs to be published quickly, you can contact 152 Publishing the editors of your journal of choice and put this thought to them, or consider writing a rapid communication. If you ask the editor to fast track your paper, you can expect one of three possible answers that will arrive back to you within days.

Lerman J quality zebeta 5 mg, Emans J buy zebeta 5mg on-line, Millis M purchase zebeta 10mg, Share J buy zebeta 10 mg low cost, Zurakowski D purchase zebeta 5mg amex, Kasser J (2001) dysplasia. J Pediatr Orthop 4: 735–40 Early failure of Pavlik harness treatment for developmental hip 33. Graf R, Tschauner C, Steindl M (1987) Ist die IIa-Hüfte behan- dysplasia: clinical and ultrasound predictors. Ergebnisse einer Langsschnittuntersuchung 348–53 sonographisch kontrollierter Säuglingshüften unter dem 3. Ludloff (1908) Zur blutigen Einrenkung der angeborenen Hüftlux- sus linear scanning? Green NE, Lowery ER, Thomas R (1993) Orthopaedic aspects of screening for neonatal hip instability. Guille JT, Forlin E, Kumar J, MacEwen GD (1992) Triple osteotomy 534–8 of the innominate bone in treatment of developmental dysplasia 59. Mayo K, Trumble S, Mast J (1999) Results of periacetabular oste- of the hip. J Pediatr Orthop 12: 718–21 otomy in patients with previous surgery for hip dysplasia. Hailer NP, Soykaner L, Ackermann H, Rittmeister M (2005) Triple Orthop 363: 73–80 osteotomy of the pelvis for acetabular dysplasia: age at operation 60. Mostert A, Tulp N, Castelein R (2000) Results of Pavlik harness and the incidence of nonunions and other complications influ- treatment for neonatal hip dislocation as related to Graf’s sono- ence outcome. Myers S, Eijer H, Ganz R (1999) Anterior femoroacetabular impinge- holm T (1990) The Swedish experience with Salter’s innominate ment after periacetabular osteotomy. Clin Orthop 363: 93–9 osteotomy in the treatment of congenital subluxation and dislo- 62. Ombrédanne L (1923) Précis clinique et opératoire de chirurgie cation of the hip. Ortolani M (1937) Un segno poco noto e sua importanza per la of the hip. Clin Orthop 281: 22–8 diagnosi precoce de prelussazione congenita dell’anca. Harris IE, Dickens R, Menelaus MB (1992) Use of the Pavlik harness 45: 129 for hip displacements. Hefti F, Morscher E (1993) The femoral neck lengthening oste- factors in ultrasound surveillance of developmental dysplasia otomy. Hefti F (1995) Spherical assessment of the hip on standard AP ra- 87:1264-6 diographs: A simple method for the measurement of the contact 65. Pavlik A (1957) Die funktionelle Behandlungsmethode mittels Rie- area between acetabulum and femoral head and of acetabular menbügel als Prinzip der konservativen Therapie bei angeborener orientation. Pemberton PA (1965) Pericapsular osteotomy of the ilium for agnosis of neonatal congenital dislocation of the hip. A decision treatment of congenital subluxation and dislocation of the hip. Plaster RL, Schoenecker PL, Capelli AM (1991) Premature closure angeborenen Hüftgelenkverrenkung. Med Klin 21: 1385–8, 1425–9 of the triradiate cartilage: A potential complication of pericapsular 45. Hoaglund FT, Healey JH (1990) Osteoarthritis and congenital dys- acetabuloplasty. J Pediatr Orthop 11: 676–8 plasia of the hip in family members of children who have congeni- 68. Pravaz CG (1847) Traité théorique et pratique des luxations congé- tal dysplasia of the hip. Rombouts JJ, Kaelin A (1992) Inferior (obturator) dislocation of S, Terjesen T (2002) Universal or selective screening of the neona- the hip in neonates. Hopf A (1966) Hüftverlagerung durch doppelte Beckenosteoto- Zielhuis GA, Kerkhoff TH (2005) The natural history of develop- mie zur Behandlung der Hüftgelenkdysplasie und Subluxation bei mental dysplasia of the hip: sonographic findings in infants of 1-3 Jugendlichen und Erwachsenen. J Bone Joint Surg (Br) 43: 518–37 » The outlook in Perthes can be very grim, 72.

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The Pain Anxiety Symptoms Scale: Develop- ment and validation of a scale to measure fear of pain generic 10mg zebeta amex. Generalized hypervigilance in fibro- myalgia: Evidence of perceptual amplification cheap 5 mg zebeta amex. A survey of children’s acute cheap zebeta 5 mg with mastercard, recurrent generic zebeta 5 mg visa, and chronic pain: Validation of the pain experience interview zebeta 10mg sale. Behaviours care- givers use to determine pain in non-verbal, cognitively impaired individuals. Sex differences in thermal nociception and morphine antinociception in rodents depend on genotype. Culture and gender effects in pain beliefs and the prediction of pain tolerance. The effect of ethnicity on prescriptions for patient-controlled analgesia for post-operative pain. Pain amongst ethnic minority groups of South Asian origin in the United Kingdom: A review. The influence of culture on pain in Anglo and His- panic children with cancer. Journal of the American Academy of Child and Adolescent Psychia- try, 29, 642–647. Social variables affect phenotype in the neuroma model of neuropathic pain. The effects of patient sex and race on medical students’ ratings of quality of life. Sex differences in the perception of noxious experimental stimuli: A meta-analysis. Pain response in Chinese and non- Chinese Canadian infants: Is there a difference? Interactions of a history of migration with the course of pain disorder. Chronic low back pain patients around the world: Cross-cultural similarities and differences. Comparison of perception of angina pectoris during exercise testing in African-Americans versus Caucasians. Ethnic differences influ- ence care giver’s estimates of pain during labour. Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Ethnic differences among housewives in psychophysical and skin potential responses to electric shock. Different approximations of the McGill Pain Questionnaire in the Norwegian language: A discussion of content validity. Ethnicity as a risk factor for inadequate emer- gency department analgesia. Pain, disability, and physical function- ing in subgroups of patients with fibromyalgia. Comparison of symptoms in Japanese and American depressed primary care patients. Gender role expecta- tions of pain: Relationship to experimental pain perception. Sensory decision theory and visual analogue scale indices predict status of chronic pain patients six months later. CHAPTER 7 Social Influences on Individual Differences in Responding to Pain Suzanne M. Mason Department of Psychology, University of Bath This chapter explores how individuals respond to pain in the context of the wider social and cultural environment. Individual differences are discussed within the framework of a model of the psychological and social factors im- plicated in the generation and maintenance of a chronically painful illness (Skevington, 1995). This model is described and elaborated in the light of emerging empirical evidence in the field of pain to address the question of what determines how people respond to pain.

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The discussion is general and therefore applicable to all specialists doing burn surgery generic zebeta 5 mg on-line. However purchase 10 mg zebeta with amex, some of this information is by necessity an opinion and should be treated as such discount 5 mg zebeta amex. Some local practices followed at different institutions may differ significantly from what is espoused here; however purchase 5mg zebeta, they all should adhere to the general principles of burn surgery buy 5mg zebeta otc. GENERAL PRINCIPLES The intent of burn wound operations is twofold: to remove devitalized tissue and restore skin continuity. The Major Burn 223 The techniques used to achieve these goals are numerous; the choice of which is the challenge and art of burn surgery. Excision In concept, the first part of the operation involves removal of devitalized tissue injured in the burn. This tissue by definition does not receive blood supply and provides an excellent environment for the proliferation of micro-organisms. Therefore, no advantage exists in leaving this eschar in place on a burn wound, and it should be removed. The removal of eschar to viable tissue provides a wound base that can be used for wound closure with skin grafts or flaps. However, aggressive debridement that removes otherwise viable tissue under the eschar should be discouraged, because all tissue layers, including fat layers, provide function and cosmesis. The intent of excision, therefore, is to remove the burn eschar to the level of viability without disturbing underlying structures. Wound Closure Once a viable wound bed is achieved, the next goal is wound closure. This should be accomplished while minimizing scarring both in the excised wound and in donor sites from which skin grafts are taken (if this approach is used). The selec- tion of method will therefore depend on the size of the wound and availability of donor site, and the functional and cosmetic importance of the wounded area. For example, a burn on the face is of great cosmetic and functional importance: Therefore, any skin grafts used there should be taken from a part of the body that will provide a good color match. Treatment and application of the autograft skin should be such that minimal disruption in all layers of the skin occurs, and lines in the grafts are minimized. In my practice, I use relatively thick skin grafts taken from the scalp applied in sheets and fashioned to the cosmetic units of the face for such injuries to address all of these concerns. This allows for minimized scarring of the wound, and donor site scarring is lessened in significance because the autograft is taken from the scalp, which will have natural camouflage if there is normal hair growth. This is an example of how the operative plan may change based on the area of the burn. Once the techniques for excision and closure of the wound are chosen, care must be taken to provide a technically sound result. Although in small burns local flaps can be used for wound closure, most significant burn wounds will require closure with skin grafts. These are applied to wound beds where the cells of the graft are kept alive by nutrients in the serum produced by the wound bed until vascularization takes place (1–4 days after application). For this process to take place and for the skin graft to take, four things are required: A viable wound bed No accumulation of fluid between the graft and the wound bed 224 Wolf No shear stresses on the wound Avoidance of massive micro-organism proliferation Performance of the selected technique must be reliable to ensure adequate out- come. Then meticulous attention should be paid to placing the grafts and adhering them to the wound bed. Consideration should be given to the lines inherent in placing grafts either from the meshing or the grafts themselves in order to minimize cosmetic scarring. Selection and application of the dressing are equally important: the dressing should apply pressure to the wound to minimize dead space under the graft, minimize shear stress, and provide antimicrobial properties. This portion of the operation is often overlooked, and if performed inadequately will lead to poor results. Wound Healing and Scarring The skin is made up of two distinct layers: the epidermis and dermis; function of the skin depends on the presence of both. The epidermis, made primarily of keratinocytes, provides a continuous moisture and antimicrobial barrier.

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