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By Y. Ugolf. Medical College of Wisconsin. 2018.

Chambers and colleagues have ob- served that self-report and proxy judgments of children’s pain using the very popular faces scales vary systematically as a function of whether the lower end of the scale is anchored by a neutral face or a smiling face cheap 5mg finasteride with mastercard hair loss in men knee. When a smiling face is used order finasteride 5 mg hair loss cure yellow, children tend to endorse faces indicating more se- vere pain (Chambers, Giesbrecht, Craig, McGrath, & Finley, 1999; Chambers & Craig, 2001). Thus, estimates of children’s pain, and potentially the use of potent analgesics, is influenced by biases built into the scale. Greater effort should be devoted to developing accurate and useful self-report measures. Hadjistavropoulos and Craig (2002) observed that nonverbal expressions of pain that do not fall in the self-report category are likely to be less subject to distortion than verbal report because their relatively more automatic and reflexive nature reduces their depend- ence on conscious processes and executive cognitive mediation. Nonverbal pain expression includes facial reactions, paralinguistic vocalizations, body and limb movements, visible physiological activity (e. These manifestations of pain always play an important role in pain communication, but become most vital where self-report is unavailable (e. Facial expression is recognized as being particularly important, because it plays a crucial role in normal social interchanges and can convey a remark- able amount of information. Faces are extremely plastic, tend to change rap- idly, and can represent a dramatic range of states. The Facial Action Coding System (FACS; Ekman & Friesen, 1978) provides an atheoretical, anatomi- 98 HADJISTAVROPOULOS, CRAIG, FUCHS-LACELLE cally based system designed for thorough description of facial movements that create facial expressions. A number of investigators have studied ex- pressions of pain in adults of all ages (e. Al- though some variability exists across individuals in identified features of the facial expression of pain, lowering of the brows, narrowing of the eyes, raising of the cheeks, blinking or closing of the eyes, raising the upper lip, dropping of the jaw, and parting of the lips are commonly found pain- related actions. This “fuzzy prototype” of a facial display appears relatively sensitive and specific to pain, accounting for its usefulness in clinical set- tings. There is much support for the argument that the display is relatively reflexive and automatic in nature. Evidence shows that there are real differ- ences in the specific facial actions and their timing between spontaneous and faked displays of pain, and findings indicate that people cannot fully suppress facial reactions to painful physical insult. Some evidence indi- cates, for example, that observers can discriminate between genuine, sup- pressed, and exaggerated pain expressions (Hadjistavropoulos, Craig, Had- jistavropoulos, & Poole, 1996; Hill & Craig, 2002), although the number of false positives and false negatives presently is too high for application to the individual case (Hill & Craig, 2002). Training observers to attend to spe- cific features of the facial expression can help improve accuracy rates (see Hill & Craig, in press). Nonverbal behavior represents the only form of pain expression avail- able for the assessment of pain in populations that do not have language available as a medium of communication. This is the case for infants and very young children, many children and adults with cognitive and serious psychological disabilities, people suffering traumatic brain damage, and seniors suffering from severe dementia. When the total number of people with communication impairments is considered, it represents a substan- tial proportion of the public at large (Hadjistavropoulos et al. This was recognized by the International Association for the Study of Pain in 2001 when it modified its widely endorsed definition of pain as “An unpleasant sensory and emo- tional experience associated with actual or potential tissue damage, or de- scribed in terms of such damage. The note reflects a concern for people who are unable to articulate their distress. Fortu- nately, people with communication limitations usually are quite capable of letting others know about their distress through nonverbal communica- tion channels. SOCIAL INFLUENCES AND COMMUNICATION OF PAIN 99 Nonverbal communication of pain has been explored substantially in young infants, who express distress primarily through cry, facial expres- sion, and body and limb movements. Because the facial display appears the most sensitive and specific modality of nonverbal expression, the Neonatal Facial Coding System has been developed as a measure of infant pain (Craig, 1998; Grunau & Craig, 1987, 1990). The characteristic pattern of infant pain display includes lowered brows, eyes squeezed shut, opened mouth, and deepened nasolabial furrow (the fold that extends down and beyond the lip corners). Often these displays are accompanied by a taut cupped tongue that has also been associated with other stressful states (Grunau & Craig, 1990). Infant facial expressions of pain show a greater degree of con- sistency than do adult expressions, are central to adult judgments of infant pain, provide outcome measures for analgesic trials, and demonstrate long- term impact of severe neonatal pain (Craig et al. Vocalizations, other than those with linguistic meaning, also are often present. Patients can scream, moan, or otherwise vocally express their distress when they are in pain. In infants, cry powerfully elicits parental attention from afar and effectively encodes the severity of distress, al- though the specific source of distress may not be readily identified (e.

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Military Academy Athletes with repeated episodes of cramping should demonstrate that a brief period of immobilization undergo evaluation for electrolyte or endocrine disor- (24–48 h) with the involved muscle in a lengthened ders finasteride 1mg otc hair loss cure bee. TENDON INJURY AND REPAIR Tendon injuries are secondary to direct trauma (lacer- PHARMACOLOGIC TREATMENT ations) or tensile overload finasteride 5 mg amex hair loss on dogs. The etiology of this abnor- mal bone formation is unclear but is related to the Tendons consist primarily of type I collagen fibrils, a degree of muscle injury, the region injured (quadri- proteoglycan matrix, and relatively few fibroblasts. Type I collagen consists of two alpha-I polypeptide muscle is subjected to trauma (Beiner and Jokl, 2001). These three chains Clinically there is usually tenderness, swelling, loss of are organized into a triple helix stabilized by motion, persistent warmth, and a firm mass in the area hydrogen and covalent bonds (Wood et al, 2000). The collagen triple helix molecules are aligned in ographically evident by 4 weeks and resembles a quarter-staggered arrangement to make up the mature bone by 6 months (Best, 1997). Surgical resection, if oppositely charged amino acids and contributes to necessary, should be delayed until the osteoblastic the tendon’s strength. The microfibrils are then arranged in a parallel, well ordered, and densely packed fashion. MUSCLE CRAMPS The microfibrils are combined with a proteoglycan and water matrix to form collagen fascicles. The Muscle cramps commonly affect both athletes and tendon consists of groupings of these fascicles sur- nonathletes. The gastrocnemius muscle and ham- rounded by connective tissue that contains blood strings are most commonly involved but cramping can vessels, nerves, and lymphatics (Wood et al, 2000). CHAPTER 10 MUSCLE AND TENDON INJURY AND REPAIR 59 The insertion of tendons onto bone is usually via four decreased flexibility, and joint laxity), age, gender, zones: tendon, fibrocartilage, mineralized fibrocarti- weight, and predisposing diseases (Almekinders, lage, and bone. Synovial fluid within the errors (over training, rapid progression, fatigue, run- sheath assists in tendon gliding. Tendons that are not ning surface, and poor technique), and equipment enclosed in a sheath (Achilles tendon) are covered by problems (footwear, racquets, and seat height) a paratenon. Tendons sus- PATHOPHYSIOLOGY taining compressive loads exhibit increased proteo- Repetitive load on a tendon that results in 4–8% strain glycan levels, larger proteoglycan molecules, and causes microscopic tendon fiber damage. Continued larger less dense collagen fibrils (Hyman and Rodeo, load on the tendon at this level overwhelms the 2000). Damage occurs to the col- Aging also affects the material characteristics of lagen fibrils, the noncollagenous matrix, and tendon with decreased collagen synthesis, increased microvasculature (Hyman and Rodeo, 2000). This results in a stiffer, weaker tendon (Hyman fibrin exudate, and capillary occlusion result in local and Rodeo, 2000). TERMINOLOGY Intrinsic tendon damage (tendinosis) may occur with There is significant confusion regarding the terminology continued tendon overload. Tendinitis, tendonitis, and appear as a number of histologic entities (hypoxic tendinosis are frequently used terms to describe the clin- degeneration, mucoid degeneration, fiber calcifica- ical picture of pain, swelling, and stiffness in a tendon. Paratenonitis: Inflammation of the paratenon or Researchers have demonstrated that chronic paratenoni- tendon sheath. Peritendinitis and tenosynovitis are tis can result in tendon degeneration in an animal model included in this category. Paratenonitis with tendinosis: Tendon degeneration showed no previous evidence of paratenonitis in over with concomitant paratenon inflammation 60% of patients who sustained an Achilles tendon rup- c. Tendinosis: Tendon degeneration without inflam- ture (Kannus and Jozsa, 1991). The initial paratenonitis mation may be causative factor for tendon degeneration or may d. Important factors impaired performance (Maffulli, Kahn, and Puddu, include tissue hypoxia, free radical induced tendon 1998). ETIOLOGY DIAGNOSIS The etiology of chronic tendon injuries is multifacto- The history often reveals repetitive mechanical over- rial and involves a combination of intrinsic and extrin- load. The use of corticosteroid injections around duration, frequency, or intensity of the training regi- weight-bearing tendons such as the Achilles tendon and men. The pain is frequently worse after a period of rest patellar tendon is controversial. Changes in footwear, reports of tendon rupture but there are no controlled equipment, or training surface may be present.

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The good news is that buy 1mg finasteride free shipping hair loss in men in their 20s, with good writing practice purchase 1 mg finasteride amex hair loss knoxville tn, peer review should not be too painful or too depressing. If you start with a plan in mind, design the paper with a purpose, and write in short, clear sentences, you will create a product that the reviewers will find easy to read and therefore can respond to more easily in an intellectual way. This is important because intellectual contributions are far more valuable to the advancement of papers than comments on grammar and organisation. When papers are badly constructed and poorly written, reviewers tend to concentrate on trying to fix the immediate problems of presentation rather than thinking about the content and the big picture. This, in turn, prompts an endlessly frustrating review-edit-amend roundabout without any major focus on content. Naturally, it is better if a paper stays on a sensible and planned track from day one rather than being continually pushed and pulled into everyone’s different ideas of what shape it should take. Constructing a paper with well- articulated aims from square one tends to focus on content and to ensure that major structural changes are not requested at the end, just when you thought you were finished. If you can achieve this, the whole review process is shorter and more purposeful, and everyone enjoys the rewards of seeing the paper progress quickly towards a publishable document. By asking for peer review, you are in effect asking colleagues to assist you with the scholarship of your work. You should never pass a draft out for review before it is truly ready, that is before it has reached the highest standard to which you can take it. The thoughtlessness of repeatedly handing out ill-prepared documents tends to wear reviewers down. To receive the most valuable feedback, drafts must be at the highest standard that you can possibly achieve before you ask your colleagues for comment. This will ensure that everyone spends their time efficiently because the number of drafts is minimised and the quality of the feedback is maximised. By incorporating each reviewer’s improvements before you pass the document on again, the next reviewer receives the most advanced version of your work and coauthors do not have to duplicate each other’s work. Some groups of coauthors find it is very productive to hold miniwriters’ groups and brainstorm some ideas together rather than reviewing in isolation. It is important to find a reviewing process that is both efficient and suits the work practices of your authorship team. As well as taking the coauthors’ and reviewers’ comments on board, you need to continually work on each paragraph so that the topic sentence is accurate and correct, the grammar is flawless, and the sentences have a minimum number of words and flow together nicely. This should not be an arduous task but rather a rewarding process of finding better ways to package your science, your results, and your ideas. Your paper is ready to circulate only when it gives you pleasure to read. It is up to you as the first author to decide whether you want verbal, written, or electronic feedback. Written feedback on a paper copy of your draft article is often the optimal way to proceed but this assumes that your reviewer’s handwriting is legible! There is an increased move towards electronic feedback using the “track changes” facilities of word processing packages. The problem is that if you send reviewers an electronic copy of your paper to edit on their screen, then you are in effect giving them temporary ownership of the document. Also, it can be difficult to transfer electronic changes to your master document if it has been altered since you gave a copy of it out for review. Always make sure your reviewer knows how to use the system if it is acceptable. With either paper or electronic editing, you will have to ensure that your reviewers understand that you will accept, amend, or reject their suggestions as you see fit and not necessarily accept them all per se. People often discuss how many drafts are needed before a fledgling paper evolves into a well-written paper, with numbers of 20 or 30 often suggested. However, if you think of 108 Finishing your paper a draft as a paper in progress that you hand to your coauthors for feedback, these numbers are excessive. It is much more satisfying if your paper takes shape and becomes a pleasure for your coauthors and reviewers to progress in a few drafts. It is also rewarding to find a concise way to tell people what you want them to know.

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This generally involves tion beds also subsequently came into widespread use discount finasteride 5mg on line hair loss genetics. Bone tumors have likewise Then generic 5mg finasteride overnight delivery hair loss cure in the future, in the 20th century, came the arrival of plastic, a always been with us, although these were neither correctly lightweight, dimensionally-stable material. Patients with milestone was reached in the 1940’s with the development such conditions tended to be left to their fate. We have no of the Milwaukee brace, which operates according to the evidence to suggest that the incidence of these tumors has principles of both extension and correction. Traction beds were also frequently used for The history of the conservative treatment of orthopaedic the treatment of spinal deformities. Although fractures The correction principle employed for clubfoottreat- were doubtless splinted and bandaged well before this Fa- ment also hardly changed at all for centuries after Hip- ther of Medicine appeared on the scene, we lack the writ- pocrates, even beyond the Middle Ages. The congenital aspect of the problem was development of a clubfoot splint. This and other splints of only established in the 17th century (Theodor Kerckring the time were able to maintain a particular position to a 1640–1693, Theodor Zwinger 1658–1724). This boot, which was the archetype of all current ful attempts at closed reduction were achieved by C. The work of Adolf Lorenz correction of clubfoot with plaster casts was only subse- (1854–1946) also represented a milestone in the treat- quently introduced in the 19th century. His bloodless method Congenital hip dislocation is a condition whose dis- of reduction with retention of the patient in a frog-leg semination is closely associated with civilization. It is plaster cast developed at the end of the 19th century was, largely unknown among primitive peoples, but has been for many decades, the standard method for the early known in Europe, particularly Central Europe, since an- treatment of congenital hip dislocation. The condition is even mentioned by Hip- 1968 that this plaster treatment was finally replaced by the less pronounced abducted position in a pelvis-leg cast described by Fettweis and associated with a reduced risk of femoral head necrosis. Other therapeutic landmarks included the development of splints (Hilgenreiner, Brown) and bandages (Pavlik, Hoffmann-Daimler). Numerous illustrations from the earliest his- torical records testify to the existence of such treatments [3, 7, 8]. In the 19th century, the fixation technique was significantly improved with the introduction of plaster. The actual plas- ter of Paris cast was invented by the Dutchman Antonius Mathysen in 1851. A particularly discriminating approach to fracture management, with standardization of treatment according to the type of fracture, was developed by Lorenz Böhler in Vienna at the start of the 20th century. Pliny the Elder relates how the Roman soldier Mar- cus Sergius lost his right hand in the Second Punic War (218–201 BC) and ordered an »iron hand« to be fashioned so that he was able to return to active duty in later military ⊡ Fig. In the Middle Ages, the use of prostheses as re- ment), from: Chirurgia è Graeco in Latinum conuersa, 1544. This ladder is then repeatedly raised using placements for arms and legs was widespread, in the latter ropes and allowed to fall under its own weight. One famous prosthesis wearer was Götz von Berlich- ingen, who had lost his right hand in the Landshut wars of succession (1504–1505). The options for prosthetic production were substantially increased by Otto Bock (1888–1953), who designed a system for the mass pro- duction of individual functional components. Prosthetic joints allowing much smoother movement, particularly of the lower extremity, were also developed around this time. The above-mentioned André Venel also achieved pio- neering work in another field by establishing the world’s first orthopaedic institute in Orbe (Canton of Vaud, Swit- zerland) in 1780. This institute provided conservative treat- ment exclusively for children with orthopaedic conditions. Hans von Gersdorff: Corrective knee extension, from : Feldt- an orthopaedic hospital, in 1812 in Würzburg. In France, buch der Wundarztney, 1517 Jacques Mathieu Delpech founded an orthopaedic institute 20 Chapter 1 · General in 1825 in Montpellier, while Jules-René Guerin and Charles- 1 Gabriel Pravaz began their work in an orthopaedic hospital in Paris in 1826.

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