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Although some clinical acute pain stimuli clearly call for pharmacologi- cal intervention due to their severity (surgery) discount 60 caps diabecon with mastercard, for other clinical sources of 245 246 BRUEHL AND CHUNG acute pain, such as injections and painful diagnostic procedures, exclusive reliance on pharmacological interventions may not be considered neces- sary or desirable given the brief duration of the pain, risk of side effects, or need for patients’ conscious awareness (e. Vari- ous psychologically based pain management interventions have been de- scribed for use in common clinical situations that result in acute pain (e. Although not intended to be an exhaus- tive review of the literature, this chapter describes a number of the tech- niques available and will overview evidence for their efficacy based on con- trolled clinical trials. Studies examining use of these interventions in comparison to or in conjunction with pharmacological analgesia will be summarized. Finally, issues involved in the practical use of such interven- tions in the clinical setting will be addressed. TYPES OF INTERVENTIONS Substantial research following the gate control theory of pain described by Melzack and Wall (1965) has confirmed the presence of descending neuro- physiological pathways through which psychological states can either ex- acerbate or inhibit afferent nociceptive input and the experience of pain. Al- though extreme emotional distress may be associated with stress-induced analgesia (Millan, 1986), at less extreme levels, greater emotional distress is generally associated with increased acute pain intensity (Graffenreid, Adler, Abt, Nuesch, & Spiegel, 1978; Litt, 1996; Sternbach, 1974; Zelman, Howland, Nichols, & Cleeland, 1991). Psychological strategies for managing acute pain therefore often intervene at the cognitive and physiological level to reduce distress and arousal that may lead to heightened experience of acute pain (Bruehl, Carlson, & McCubbin, 1993). In addition, the simple fact that a specific pain management technique has been provided is likely to in- crease patients’ perceived sense of control, which also appears to be an im- portant factor in reducing negative responses to painful stimuli (Litt, 1988; Weisenberg, 1987). Available psychological techniques for management of acute pain can be broadly categorized into information provision, relax- ation and related techniques, and cognitive strategies (e. Although some interventions, such as information provision, are primarily preemptive and designed to minimize pain by preparing the patient for what will be experienced, others such as relaxation techniques may be useful both preemptively and for reducing acute pain as the patient is experiencing it. Common psychological pain management techniques are summarized in Table 9.

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Bonham (2001) carefully examined disparities in health care in the United States order diabecon 60caps, indicating that “racial and ethnic minority groups often re- ceive different and less optimal management of their health care than White Americans” (p. He considered a number of possible reasons for this including stereotypes, language barriers, ineffective communication, a failure to understand the patient’s expressions of pain and distress, and so- cioeconomic factors, concluding that adequate pain assessment is the most important step in reducing inadequate patient care. The scripts were identi- cal, the clinical symptoms were sufficient for a diagnosis of definite angina, and the actors were in identical gowns and filmed in the same room. Stu- dents were less willing to provide a diagnosis of definite angina for the Black female (46%) than for the White male (72%), yet rated her quality of life as lower. The design did not allow a determination of whether this ap- parent bias in diagnosis and health status rating is based on race or sex or a combination of the two, but the data indicated that training in cultural awareness should be a required part of training for medical and other health care personnel. Insensitivity to the needs of Central American residents of the Boston area is highlighted by three simple case studies presented by Flores, Abreu, Schwartz, and Hill (2000). A 3-year-old girl, who was later found to have a perforated appendix and peritonitis, was repeatedly sent home from a hos- pital emergency department because no interpreter was available and the staff lacked kindness, friendliness, and respect; a 2-year-old girl with shoul- der pain was placed in the custody of the Department of Social Services be- cause the resident thought that the caregiver’s comment, “she was struck,” meant she had suffered abuse, rather than the intended “she had fallen off her tricycle and struck her shoulder”; and the parents of a neonate with se- vere impairments were not informed of the poor prognosis and mistakenly believed the baby would soon recover and be released. In all cases, “failure to address language and cultural issues resulted in inferior quality of care, 162 ROLLMAN adverse outcomes, increased health care costs, and parental dissatisfac- tion” (p. It is important to test for disparities in health care or undertreatment of some ethnic groups in other societies. Sheiner, Sheiner, Shoham-Vardi, Mazor, and Katz (1999), in an investigation of the childbirth experience of Jewish and Bedouin women living in the Negev section of southern Israel, almost all of whom deliver at a major regional hospital, obtained ratings of pain (from the patient, physician, and midwife) at the initial active phase of labor. There were substantial demographic differences (the Bedouin women were younger, more likely to describe themselves as religious, less likely to be accompanied at labor by their husband, had less formal educa- tion, and did not attend childbirth education classes). Epidural analgesia was offered nearly twice as often to Jewish women as to the Bedouin (who preferred parenteral pethidine, a synthetic opioid analgesic). The most interesting finding came from the concurrent visual analog scores of the mothers and the care providers. The self-assessments of the Jewish and Bedouin women were nearly identical (8. These data are different from some of those reported earlier, in that they do not show undertreatment of an eth- nic group. Both groups of women had equal (albeit high) levels of pain at the time of assessment; what differed was the pain level judged by the de- livery staff from the exhibited behavior.

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This corresponds problems cheap 60caps diabecon with amex, in 1992 Hanscom proposed a radiological to type E or type F according to Hanscom. Multiple classification, based on 64 cases, that takes better account fractures even occur during the delivery process. The commonest form is type I, type II deformities occur in varying degrees in the other types is less common, while types III–V are extremely rare. The classification according to Hanscom helps us Etiology, pathogenesis assess the severity of the condition. In Hanscom type A the The underlying problem in osteogenesis imperfecta is the vertebral bodies show normal contours, and the extremi- impaired maturation of type I collagen fibers from the ties, particularly the legs, are only slightly bowed. While osteoblast activity is brisk, the cells there is clear bowing of the upper and lower legs, with are incapable of forming normal collagen. The vertebral bodies are biconcave, and links« play an important role in the maturation of the scoliosis and/or kyphosis not infrequently develops. An collagen and their formation is impaired in osteogenesis additional factor in type C is the development of acetabular imperfecta, thereby preventing the production of polym- protrusion around the age of ten years. The enzyme defect appears to be different changes are observed from the age of five years on x-rays in the various types. Histological examination reveals thin of the distal femur and proximal tibia, and the epiphyseal bone trabeculae and decreased ground substance. Very serious spinal deformi- bone possesses numerous areas of fibrous bone with an ties are regularly present in types C and D. Fracture healing is not ditionally, the cortices of the long bones are not ossified, impaired, and very large amounts of callus are formed as a while in type F the cortices of the ribs are also missing. The following non-osseous signs and symptoms may Clinical features, diagnosis be observed: The sclerae are blue. Although the sclerae The clinical manifestation varies greatly depending on the of all neonates are bluer than those in small children, the type involved.

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Since the mechanical axis is less relevant in the sagittal plane generic diabecon 60 caps with mastercard, only the anatomical axis is used for planning. Angulation deformities are characterized by four parameters: ▬ level of the apex of the angulation, ▬ plane of the angulation, ▬ direction of the apex in the plane of angulation, ▬ extent of the angulation. In order to correct the angulation deformity, all of these parameters must be determined before the level and type of osteotomy to be performed is selected. The apex of the angulation is measured as the intersection between the proximal and distal axis lines. The extent of the angula- tion is determined at the level of the apex as a transverse angle. A line bisecting this angle is drawn through the apex, thus dividing the lon- ⊡ Fig. Treatment Conservative treatment Although numerous measures have been proposed for correcting axial and rotational deformities, none has proved completely effective to date. The list of measures starts with the instruction that the child should not be allowed to adopt a »reverse cross-legged« sitting position. In a child with increased anteversion, the hip is well centered when the legs are internally rotated. If the legs are placed in a position of external rotation, the femoral head subluxates anteriorly. For the purposes of derotation, the dynamic forces during walking are far more effective than the static forces during sitting. These extend later- ally on the leg from a hip strap to a lower leg orthosis and force the foot to twist outwards.

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