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Arch Med Res 32 (4): 277–82 orthopaedic aspects of 206 patients treated from birth with no 37 generic 20mg cialis super active amex. Mazur JM quality 20 mg cialis super active, Aylward GP, Colliver J, Stacey J, Menelaus M (1988) selection criteria. Dev Med Child Neurol 34: 1047–52 Impaired mental capabilities and hand function in myelomenin- 58. Swank M, Dias LS (1994): Walking ability in spina bifida patients: gocele patients. Z Kinderchir 43: 24–7 a model for predicting future ambulatory status based on sitting 38. Mazur JM, Sienko-Thomas S, Wright N, Cummings RJ (1990) balance and motor level. Tripathy P, Roy I, Bhattacharya MK, Banerjee SN, Roy RN (1989) thoracic-level spina bifida. McEnery G, Borzyskowski M, Cox TC, Neville BG (1992) The spinal 62–4 cord in neurologically stable spina bifida: a clinical and MRI 60. Dev Med Child Neurol 34: 342–7 (2003) Gait analysis in low lumbar myelomeningocele patients 40. Meehan PL, Galina MP, Daftari T (1992) Intraoperative anaphy- with unilateral hip dislocation or subluxation. Von Recklinghausen F (1886) Untersuchungen über die Spina allergy in children with myelodysplasia: A survey of Shriners bifida. Nesbit DE, Ziter FA (1979) Epidemiology of myelomeningocele in cholinesterase measurement in the prenatal diagnosis of open Utah. O’Neill OR, Piatt JH Jr, Mitchell P, Roman-Goldstein S (1995) cholinesterase Study. Prenat Diagn 9: 813–29 Agenesis and dysgenesis of the sacrum: neurosurgical implica- 63. Brunner thetic), reduced (hypesthetic) or even increased (hyperes- thetic). The muscle dysfunction can also manifest itself in the form of weakness or complete paresis. The pareses are > Definition always flaccid, and spasticity never occurs. The presence Nerve lesions outside the central nervous system involve of sensation and/or motor function rules out a complete the spinal nerve roots, the peripheral nerves and the ana- nerve lesion. But if complete lesions are present, only the tomical structures in plexus form located between the 4 course of the condition will show whether the neuronal two. Since the lesions affect only the axons of the nerve structures are actually interrupted or not. The lesions are subdi- that are not clinically detectable and thus enable a more vided into plexus palsies and peripheral nerve injuries. The neural structures can be Etiology and pathogenesis depicted directly on an MRI scan. Moreover, in the case of Peripheral neural structures in children can be damaged plexus injuries, the roots can be shown in their pouches as a result of a variety of injuries. Accidents are by far the most Treatment and prognosis common cause of these lesions. Unfortunately, damage Measures for nerve lesions are basically curative or pal- can also occur during birth or as a result of therapeutic liative. Nerves can be injured by conservative treat- A curative procedure is suturing of the damaged ments such as plaster casts or dynamic splints (peroneal nerve, with or without interposition. The prognosis is nerve paresis as a result of pressure exerted by a cast on better for early than for late interventions and better for the fibular head is a familiar example). On a proximal extrem- Damage to the peripheral nervous system can also ity, a success rate of 80–90% can be expected after early occur during major treatments such as limb lengthen- reconstruction. The results are not so good for a lower ing procedures or, during surgery, by positioning aids extremity, particularly if the peroneal nerve is involved or surgical instruments. For secondary procedures, the results are worse outside the CNS can vary according to the frequency and by 10–20% [1, 7, 8]. A pathophysiological distinction Prognostically negative factors in relation to the results is made between a neurapraxia, an axonotmesis and a after reconstructive operations: neurotmesis. In extension of the lesion, axonotmesis the axons are interrupted, although the key certain nerves (e.

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Improved patient care in the severely burned buy cialis super active 20 mg cheap, including operative strategy and techniques discount 20mg cialis super active with mastercard, has undoubtedly improved survival, particularly in children. Bull and Fisher first reported in 1952 the expected 50% mortality rate for burn sizes in several age groups based upon data from their unit. They reported that approxi- mately one-half of children aged 0–14 with burns of 49% total body surface area (TBSA) would die, 46% TBSA for patients aged 15–44, 27% TBSA for those 221 222 Wolf of age 45–64, and 10% TBSA for those 65 and older. The dramatic effect of the practice of early wound excision on burn mortality cannot be overempha- sized. This single advancement has led, in my opinion, to the routine survival of patients with massive burns in centers with experience in their care. Burn wounds can be roughly categorized into two classes: partial-thickness and full-thickness. Partial-thickness wounds will generally heal by local treatment with skin substitutes or topical antimicrobials, and therefore do not require opera- tive treatment. Full-thickness and very deep partial-thickness wounds, however, will require other treatments to affect timely wound healing. Since all the elements of the epidermis have been obliterated in full-thickness wounds, healing can occur only through wound contraction and/or spreading epithelialization from the wound edges. In a sizable wound, this process will take weeks to months to years to complete. To accelerate this process, skin grafting with the necessary keratinocytes from other parts of the body can be used. Alert patients do not generally tolerate this procedure, so anesthesia is necessary. Therefore, these procedures to accelerate burn wound closure are performed in the operating room. This chapter reviews the general principles of burn surgery, defines which patients should receive operations for burn wound closure, discusses necessary equipment and skills including patient preparation, reviews an excision and grafting proce- dure for a major burn, and discusses the techniques generally chosen based on the patient and injury characteristics. The discussion is general and therefore applicable to all specialists doing burn surgery. However, some of this information is by necessity an opinion and should be treated as such. Some local practices followed at different institutions may differ significantly from what is espoused here; however, they all should adhere to the general principles of burn surgery. 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.

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We need to invest in understanding the variables that me- diate this and other important factors and elucidate the impact that living with pain has on a person’s quality of life buy generic cialis super active 20 mg online. Ultimately cialis super active 20 mg amex, quality of life is about people’s “goals expectations, standards and concerns” (WHOQOL Group, 1995) and how far these are satisfied. A person’s quality of life and well- being may impact on his or her response to pain, and vice versa (Skeving- ton, 1998; Skevington, Carse, & Williams, 2001). In addition, beliefs about quality of life may be mediated by these concepts that are heavily culturally determined (WHOQOL Group, 1995), and all the processes identified in the model impact on decision making regarding quality of life. Before summing up, two additional sections have been added to satisfy different purposes. In the first, we outline an example of a pertinent socio- cultural issue that reflects and is reflected by individual differences, and seek to show how key issues may be addressed in different ways, cutting across all levels of the model. Although no claim is made for the compre- hensiveness of the model’s components, such examples illustrate that there is some semblance of gestalt, with the whole being more than the sum of the parts. Gender was chosen as the example because it represents an important issue that has widespread influence on individual differences in terms of pain experience and report. The second section provides some limited observations on methods in this area. GENDER: AN EXAMPLE OF FEATURES THAT MAY BE ADDRESSED AT ALL LEVELS OF THE MODEL Central to the debate around gender and pain is epidemiological evidence of more frequent symptom reporting and/or help seeking by women than men (Berkley, 1997; Unruh, 1996), and the greater prevalence of certain con- ditions, like fibromyalgia, in women (Yunus, 2002). Individual differences ex- plained by gender are conceptually important at all levels of the proposed model, although there has been a tendency to focus on a limited number of gender differences at the expense of what are seen as less interesting but more frequently occurring similarities. SOCIAL INFLUENCES ON PAIN RESPONSE 199 importance of socialized gender patterns and sociocultural expectations of pain reporting and help seeking, which shape the behavior of men and women. At Levels 2 and 3, women are seen as highly social in the ways they seek out social information for decision making and actions relating to pain. In interaction with health professionals, women communicate in different styles and receive different treatments for the same conditions (Verbrugge, 1989; Verbrugge & Steiner, 1984, 1985). Differential perceptions of various aspects of quality of life (WHOQOL Group, 1995), and gendered ideologies, histories, and cultures connected with health and health care, as well as lower income, are indicated as relevant factors at Level 4. Factors addressing features from all these levels seem to be evident in Bendelow’s (1993) in-depth qualitative study, which explored women and men’s experience of and beliefs about causes of pain. Both gender groups believed that women were better able to cope with pain, and provided so- phisticated biological and sociocultural explanations for this. Bendelow also found that pain was seen as “normal” for women because of painful ex- periences associated with the reproductive process, particularly childbirth. In contrast, men were not only discouraged from expressing pain but at the same time were encouraged to deny pain and be stoic. More recently, ex- perimental research with the cold-pressor task has shown differences in the perception of and response to coping with pain among men and women. This was particularly evident where sensory- or emotion-focused coping instructions were given (Keogh & Herdenfeldt, 2002). In general, it appears that women are more vulnerable to pain than men but they have a larger repertoire of ways to deal with it (Berkley & Holdcroft, 1999). The impor- tance of understanding gender issues around pain hinges on the ability of therapists to maximize therapies or interventions designed to relieve or im- prove the management of pain, including a greater understanding of differ- ential patterns of expressing pain. MEASURING THE RESPONSE TO PAIN AT ALL LEVELS The literature on measurement of pain (see chap. Increasingly, attention is being paid to the reliability of in- 200 SKEVINGTON AND MASON struments purporting to measure pain and, in particular, to the challenging issue of pain measurement in pediatrics. The social context of pain measurement has also been studied; for exam- ple, Kelleher and colleagues provided preliminary evidence that pain scores are influenced by the social context in which they are obtained (Kelleher, Rennell, & Kidd, 1998). This provides additional support for the model outlined in this chapter and the importance of including, accounting for, and exploring the social factors that mediate the response to pain. Countless instruments and indexes are used in the clinic and for re- search into the complex, multifactorial response to pain. For example, based on a cognitive affective model of pain where pain interrupts and de- mands attention (Eccleston & Crombez, 1999), the Pain Vigilance and Awareness Questionnaire (McCracken, 1997) was developed, and this was recently adapted this for use with a subclinical sample, including diagnoses other than low back pain (McWilliams & Asmundson, 2001).

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