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Patient-Related Issues Patients with chronic nonmalignant pain often have no identifiable anatomic lesion that PCPs can point to as a clear cause of pain and that buy discount lanoxin 0.25mg online blood pressure young female, in a doctor’s mind cheap 0.25mg lanoxin with visa blood pressure 200100, better justifies the use of long-term strong opioid medications. Without objective evidence of pathology, there is less to counter the multi- ple forces that weigh in on the side of not prescribing opioids. If PCPs choose Opioids for Chronic Pain in Primary Care 139 Pressures against prescribing Fear of being duped Lack of clear guidelines Criminal justice Fear of addiction DEA system Productivity and time Controversy over effectiveness Patient characteristics: of opioids in chronic pain demanding, personality disorders, comorbid depression Primary care physicians Medical boards Desire to help Patients JCAHO Pharmaceutical companies Pressures for prescribing Fig. Pressures on PCPs against and for prescribing opioids for chronic nonmalig- nant pain. Research has shown that chronic pain patients tend to have a higher preva- lence of comorbid psychiatric disorders, such as depression and borderline personality disorders, and that the presence of these conditions is associ- ated with poorer pain control. Within the past 20 years, PCPs have improved significantly in their treatments of depression, but when depres- sion is combined with chronic pain and personality disorders, these patients often become complicated and frustrating. Prescribing opioids in these situa- tions is something PCPs usually might try to avoid although opioids may be the appropriate treatment depending on the diagnosis, and the type and chronicity of the patient’s pain. If patients feel that their pain is not adequately addressed, they may become demanding and sometimes can give the appearance of being drug-seeking or addicted when in reality they are not. If patients have a history of substance abuse, then the treatment of chronic pain becomes even more difficult for PCPs. This group of patients has almost 4 times the odds of exhibiting prescription opioid abuse behaviors compared to patients without a lifetime history of substance abuse. Often in these patients, however, it becomes difficult to distinguish whether the substance abuse, including prescription pain medicine addiction, came about as a Olsen/Daumit 140 consequence of chronic pain treatment or whether the substance abuse is exac- erbating the chronic pain symptoms. Physician-Related Issues Ask most physicians about why they chose their profession and you will hear the same answer – to in some way or another help people. At medical school graduations across the country, new MDs swear to some version of the Hippocratic oath, promising to live up to this responsibility. When faced with patients who demand extra time and extra attention in the midst of all the pres- sures PCPs face to not prescribe opioids, the Hippocratic oath may become harder to follow. Although no empiric data exists on the difference in lengths of visit in primary care settings for chronic pain patients compared to patients with other chronic diseases of similar severity, busy practitioners faced with demanding chronic pain patients may undertreat or overtreat the pain by hand- ing patients prescriptions for various analgesics, including opioids, without taking the time to really listen to, talk with, or examine them. The data on the addictive potential of opioid prescription drugs is variable, but the fear of creating addicts is one of the most often cited reasons why PCPs feel uncomfortable prescribing opiates. The studies that have addressed this have found that 4% to 31% of patients without substance abuse histories seen in primary care clinics exhibit addictive behaviors with respect to their prescription pain medications. Differences in patient population and different definitions of addiction may explain the variable rates of opioid use disorders noted across these studies. Recent abuses and overdose fatalities from Oxycontin®™ have added fuel to PCPs’ fears of creating addicts in managing chronic nonmalignant pain with opioids. One physician-related issue not often discussed in the debate over the use of opioids by PCPs in the treatment of chronic nonmalignant pain is the fear on the part of PCPs of being duped. No one likes having the wool pulled over their eyes but PCPs pride themselves on the continuity they have with patients and the ability to develop ongoing, meaningful therapeutic relationships with their patients. If the trust developed in that relationship is broken, then PCPs may feel extremely taken advantage of, deceived, and betrayed by someone they were investing time and energy in to help. Although physicians are taught to practice according to evidence-based guidelines, experiences such as these are bound to taint PCPs’ outlooks on similar patients they may encounter. In many areas of the country, particularly rural areas, PCPs also have rel- atively little specialty back up to help guide them in managing difficult patients with chronic nonmalignant pain. Without such resources to turn to, PCPs are Opioids for Chronic Pain in Primary Care 141 left to often conjecture when they should be using other modalities such as ultrasound or pharmacotherapies such as Neurontin, Topamax, or opioids. Medical school and residency curricula and continuing medical education on chronic pain, its evaluation, and treatment are sorely lacking [22, 23]. Residents, faculty, and private PCPs alike bemoan the presence of ‘drug- seeking’ chronic pain patients on their clinic schedules, but partly this stems from their lack of knowledge about how to adequately handle these patients, how to appropriately prescribe opioids, dosing of longer-acting, stronger agents, and the latest techniques for treating chronic pain. Without confidence in their skills and ability to manage chronic nonmalignant pain, PCPs become more sus- ceptible to the various other pressures that influence their prescribing of opioids. James Graves of Florida became the first physician in the country to be convicted of manslaughter for contributing to the fatal over- doses of patients by prescribing Oxycontin. Prior to and following his conviction, numerous other physicians, from family physicians to pain special- ists in Maine, California, Florida, and South Carolina, have been charged with racketeering, drug dealing, and manslaughter through prescribing Oxycontin to patients who subsequently died of overdoses [24–27]. PCPs understandably would feel increasingly uncomfortable even legitimately prescribing opioids if they thought they could be faced with a remote possibility of loss of their license and livelihood, jail time, or public humiliation.

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Knee liga- lack of effective anesthetic techniques cheap lanoxin 0.25 mg on line blood pressure food, speed was an im- ment reconstruction lanoxin 0.25 mg online blood pressure chart young adults, in particular, flourished during this portant requirement in performing the procedure. Although rarely performed on children, this pro- from amputations, the only other orthopaedic proce- cedure certainly is of relevance for adolescents. During the 1950’s, Gavril Ilizarov in Russia developed the The two important preconditions for the develop- ring fixator for which he is named. Surgeons in Europe ment of surgical orthopaedics were only satisfied in the and America remained unaware of this development for mid-19th century: Anesthesia and asepsis. The pioneers a long time and instead used the apparatus introduced by in anesthesia were the Boston dentist William Thomas Heinz Wagner in the 1960’s. It was not until the 1980’s that Morton who, in 1846, was the first to administer an the Wagner lengthening method was abandoned in favor ether anesthetic, and the doctor James Young Simpson in of the Ilizarov technique. Many other unilateral devices Edinburgh who, in 1847, used chloroform in obstetrics. An important forerunner in employing asepsis was Ignaz Pioneers in surgical fracture treatment at the start of Philipp Semmelweis (1818–1865) in Vienna, Austria, while the 20th century were A. At the start of the 1960’s the Association for a result of these developments, complex operations soon the Study of Internal Fixation (AO/ASIF) in Switzerland became a possibility. The stable While isolated attempts at osteotomy date back to the techniques of internal fixation developed by the AO/ASIF era before anesthesia, this operation only gained accep- also play an important role in pediatric orthopaedics (pri- tance in the second half of the 19th century. Pioneers in marily in connection with osteotomies), although even this field were Bernhard Langenbeck and Theodor Billroth, today the plaster cast and certain »unstable« internal the latter introducing the use of the chisel. By the fixation methods are much more prevalent in the fracture end of the 19th century, bloody reduction was commonly treatment of children than stable osteosynthesis proce- employed for hip dysplasia, and arthrodeses were also dures, which are only indicated in exceptional cases. Methods for lengthening muscles and tendons for The surgical treatment of malignant bone tumors pre- the treatment of the consequences of poliomyelitis were dominantly involved amputation up until the end of the developed at the start of the 20th century. It was only with the development of modern che- were Oskar Vulpius and Richard Scherb. While experi- tumor surgery was able to progress in the 1980’s and 90’s. In pediatric orthopaedics, arthroplasties into a healthy organ, they can merely steer the body’s are only relevant in the context of malignant bone tumors own healing powers in a positive direction. Spinal fusion first fundamental insights were published by Julius Wolff was introduced by R. Hibbs and fixed postoperatively (1836–1902) in his treatise entitled Gesetz der Transforma- in a plaster cast. At the end of the 1950’s Paul Harrington tion der Knochen [The law of the transformation of bone] in Houston developed instrumentation for the posterior (1892). At the start is deposited and resorbed in response to increased and of the 1960’s, A. Spinal surgery experienced aptation« originates from Wilhelm Roux (1850–1924). In 22 Chapter 1 · General his publication Der Schenkelhalsbruch, ein mechanisches 1. Such model-specific ideas are generally based That’s strange, for we don’t have eyes in the back on static considerations. The first scientific exami- nation of the human gait was published in the monograph by W. Fischer entitled Der Gang des Men- Achievements of recent decades schen [The human gait] (1896–1903), in which the kine- Orthopaedics has grown considerably in importance as matics of a walking soldier was measured in minute detail. This is largely attributable Since the 1960’s gait laboratories have been established to the application of endoprosthetics in the treatment of in various centers. But internal fixation techniques for fractures, methods are now used to calculate forces and torques arthroscopy and ligament reconstruction for the knee in the joints during the dynamic process of walking and and shoulder, and new instrumentation systems in spinal produce conclusions for subsequent treatments. This is a surgery have also contributed to the revival of this spe- very valuable technique especially for patients with neu- cialty. But significant developments plines of medicine, the invention of the x-ray by Wilhelm with benefits for children and adolescents have also Conrad Röntgen in 1895 was of crucial importance.

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Abduction with pronation and The medial ligamentous structures are tensed and may result in external rotation the eventual avulsion of the medial malleolus 0.25 mg lanoxin amex blood pressure newborn. Lateral displacement of the tibial epiphysis allows forward and lateral talar rotation to generate a greenstick or spiral fibular fracture (Salter-Harris type II injury) order 0.25 mg lanoxin visa prehypertension medication. Supination with external The medial structures are relaxed so forcing the talus backwards rotation and into external rotation to create an oblique distal fibular fracture. Further talar rotation will result in the distal tibial epiphysis being displaced postero-laterally with an associated posterior metaphyseal fragment. The Ottowa ankle rules, although not specific to children, can guide the referrer in the need for radiographic assessment of ankle injuries17 and it is important that the radi- ographic images are of diagnostic quality. The radiographic projections of choice are the standard mortise and lateral ankle projections. The foot Variation in the ossification and fusion dates of the pedal epiphyses frequently leads to confusion in the identification of trauma, particularly in the infant when minimal tarsal ossification has occurred. A useful evaluation technique is there- fore to remember that in feet of all ages, the talus should point to the first metatarsal and the calcaneum to the 4th or 5th metatarsal (see Chapter 8). The calcaneum Calcaneal fractures are rare in pre-adolescent children and, should they occur, tend to be extra-articular and involve the tuberosity2. In older children, calcaneal Skeletal trauma 159 fracture patterns mimic those of the adult; however, the associated incidence of spinal fractures is reduced. Occult ‘toddler’ stress fractures may present in the pre-school child but plain film examination is often negative and the use of alter- native imaging modalities (scintigraphy or MRI) should be considered. The talus Injuries to the talus must be identified owing to their propensity to develop avas- cular necrosis. In children, most injuries tend to involve the talar neck and a variety of fracture patterns (complete and incomplete) may be seen. The metatarsals Injury to the metatarsals in children under 5 years of age tends to be confined to the 1st metatarsal whereas metatarsal injury in children over the age of 10 years 19 is focused upon the 5th metatarsal. An exception to this may be a physeal frac- ture at the base of the first metatarsal, usually a Salter-Harris type II injury, that may be seen in young adolescents and results from a fall from height. The apo- physis of the peroneus brevis can be seen as a vertically orientated ‘flake’ of bone adjacent to the base of the 5th metatarsal on foot radiographs of older children (Fig. The phalanges Fractures to the phalanges may be transverse, oblique or epiphyseal in nature and, with the exception of the distal phalanx of the great toe, have no obvious prognostic complications (Fig. The nail bed of the great toe is attached to the physeal plate of the distal phalanx and, as a result, forced flexion injuries (i. This type of injury provides a route for the spread of infection from the nail bed to the underlying bone (osteomyelitis) and antibiotic treatment should be prescribed as a preventative measure. The axial skeleton The cervical spine Traumatic injury to the paediatric cervical spine is rare as the neck is more flex- ible in children than in adults therefore allowing injury forces to spread along the length of the spine and reduce the likelihood of focal bony trauma6. If trauma does occur then it is likely to be concentrated in the upper cervical region (C1–C3) in children under 10 years of age. In older children, cervical spine trauma pat- terns mimic those seen in the adult patient. The injury mechanism for cervical 160 Paediatric Radiography Fig. Specific paediatric cervical spine injuries and their associated radi- ographic clues to diagnosis are described in Table 7. The radiographic projections of choice for imaging the cervical spine follow- ing injury are the antero-posterior projection of C3–C7 and C1–C3, and the lateral projection from which most diagnoses will be made (Fig. It is essential that the radiographs produced are of a high technical standard to facilitate accurate interpretation and prevent misdiagnosis. Clinical evaluation of the radiographs should include assessment of bony alignment (anterior and posterior vertebral body lines and spino-laminar line), evaluation of vertebral disc and body heights for anatomical consistency, assessment of the relationship between C1 and C2 Skeletal trauma 161 Fig. Injury description Radiographic diagnostic clues Fracture through ring of C1 Loss of bony alignment Bilateral overhanging of lateral masses of C1 on C2 seen on antero-posterior projection Computed tomography (CT) may be useful Torticollis Spine tilted and rotated on antero-posterior projection (head tilting towards painful side) Rotation of C1 on C2 on antero-posterior projection Rotational subluxation at the Rotational asymmetry of C1 lateral masses about odontoid peg atlanto-axial joint on antero-posterior projection Condition usually self-limiting but if it fails to resolve, CT may be useful for assessment purposes Odontoid peg fracture Results from acute hyperflexion (e.

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Much of the information processing is unconscious generic 0.25mg lanoxin with amex arrhythmia guidelines 2011, and physiologi- cal responses are initially unconscious discount lanoxin 0.25mg with mastercard blood pressure chart vs age, producing affective changes and subsequent awareness of emotional arousal. The HPA axis plays a strong role in emotional arousal and the defense response, and it helps govern the immune system (Sternberg, 1995). The immune system does much more than identifying and destroying foreign substances: It may function as a sense organ that is diffusely distributed throughout the body (Blalock, Smith, & Meyer, 1985; Willis & Westlund, 1997). Some investigators contend that the brain and immune system form a bi- directional communication network (Lilly & Gann, 1992; Maier & Watkins, 1998). First, products of the immune system communicate injury-related events and tissue pathology to the brain. The key products are cytokines such as interleukin-1 (IL-1) and interleukin-6 (IL-6) released by macrophages and other immune cells. They appear to do this not by functioning as blood- borne messengers, but by activating the vagus nerve. Paraganglia sur- rounding vagal terminals have dense binding sites for IL-1, and they syn- apse on vagal fibers that terminate in the solitary nucleus. Thus, cytokines appear to excite (albeit indirectly) vagal afferents that terminate in one of the major control centers for the autonomic nervous system. Second, the brain controls the immune system via the actions of the sympathetic nervous system and the hypothalamic secretion into the blood- stream of releasing factors that activate the anterior pituitary via the HPA axis (Sternberg, 1995). The pituitary body releases peptides related to pro- opiomelanocortin, such as ACTH and beta-endorphin, and these in turn trig- 78 CHAPMAN ger the release of glucocorticoids. Because the cells and organs of the im- mune system express receptors for these hormones, they can respond to humoral messenger molecules of central origin. This system is important for pain research because, according to Maier and Watkins (1998), activa- tion of these pathways by a stressor such as tissue trauma produces a con- stellation of adaptive behaviors and physiological changes that correspond to the “sickness” response. The sickness response is a negative experience, but it evolved to promote recuperation and survival. It includes fever, increased slow-wave sleep, increased leucocytosis, reduced exploration, diminished sexual interest, re- duced activity, depressed mood, and somewhat diminished cognitive abili- ties. Collectively, these responses conserve energy and foster its redirec- tion to increased body temperature, which suppresses the reproduction of microbial organisms. Sickness tends to occur with both microbial infection and tissue injury because an open wound normally invites infection. Viewed broadly, sickness is an unpleasant motivational state that promotes recuperation. These considerations suggest that feeling sick is a part of the brain’s de- fense against microbial invasion. Tissue trauma can provoke it, and thus it tends to accompany the experience of pain. Obviously, chronic sickness in the absence of definable injury of pathology serves no biological purpose. CLINICAL IMPLICATIONS The preceding review reveals that the brain deals in complex ways with sig- nals of tissue trauma. It is rarely reasonable to assume that psy- chological processes are incidental to pain; indeed, pain is itself a psycho- logical experience, and the expression of pain is a behavior. Highly organized patterns of protective response occur during pain, and they involve the autonomic nervous system, the HPA axis, and the immune system, as well as subjective awareness. Negative emotion is a major fea- ture of pain and a direct consequence of complex central nociceptive proc- essing involving sympathetic activation and activity in the HPA axis. Emo- tion is not purely subjective, and its psychophysiology can be medically significant. Cognitive processes invariably accompany human emotion, so they are a part of the pain experience. If the emotional component of pain is an integral part of the experience of pain, with its own physiological mechanisms, then it stands to reason that medicine should incorporate the affective dimension into diagnosis of 3. Mechanisms of pain and related interventional strategies, organized according to levels of the neuraxis. Most physicians try to look around or beyond the negative emotion that the pa- tient in pain presents in an attempt to discern whether the pain sensation signals an undiagnosed injury or disease process. This is a necessary first step, but when the results are negative, it is important to assess the pa- tient’s affective status.

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