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By F. Ateras. Northwest University.

Williams buy discount hoodia 400 mg online herbs used in cooking, DO buy 400mg hoodia overnight delivery herbs chambers, MEd, Assistant Professor of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland Pamela M. Williams, Assistant Professor of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland Tory Woodard, MD, Chief Resident, Department of Family Medicine, Malcolm Grow Air Force Medical Center, Andrews Air Force Base, Maryland David C. Young, MD, Sports Medicine, The Permanente Medical Group, Department of Orthopedics, South San Francisco, California Joseph J. Zuback, Orthopaedic Service, William Beaumont Army Medical Center, Texas Tech UHS, El Paso, Texas PREFACE In the spring of 1993, primary care sports physicians across the country were scrambling to identify good resources to prepare for the first examination for a Certificate of Added Qualification in Sports Medicine. This examination was co-sponsored by the American Boards of Family Practice, Internal Medicine, Pediatrics, and Emergency Medicine. At review courses a common theme was that at that time, there was no identifiable source that reliably identified the dis- cipline of sports medicine, let alone a good review book or study guide. Since that time, of course, there have been a number of excellent books published in the field of primary care sports medicine. At the Annual Meeting of the American College of Sports Medicine in 2002, Darlene Cook of McGraw-Hill approached me about a new line of textbooks that their company was developing called Just the Facts. Darlene, who had mentored Robert Wilder and myself through our first book, Running Medicine, stated that McGraw-Hill’s market research had identified a need by clinicians for sources of essential information in an outline format that provided quick reference. Darlene also felt these books would provide excellent sources of study for clinicians facing initial certification examinations or recertification exams. As I was beginning to prepare for my ten-year recertification in sports medicine since my initial examination in 1993, I thought it would be an inter- esting endeavor. Robert Wilder, a physical medicine and rehabilitation physician and my colleague on a number of academic pursuits. We decided to include a second sports medicine physician, as this would be an ambitious project, as well as an orthopedic surgeon to hopefully recruit the most expertise in opera- tive orthopedics. Robert Sallis, an author- ity in primary care sports medicine and fellowship program director, accept our invitation. Pierre, a sports trained orthopedic surgeon and edu- cator, graciously agreed to coordinate our orthopedic chapters. As a multi- disciplinary group, our goal became to develop a text that would have value among a variety of clinicians involved with sports medicine including medical doctors, surgeons, allied healthcare professionals and athletic trainers. Our vision was a well-referenced, evidenced-based source of material that would provide a resource for both study and practice. A quick look at the author list identifies for the reader a number of “who’s who” leaders in the field of sports medicine. Interspersed among the “giants” in xix Copyright © 2005 by The McGraw-Hill Companies, Inc. A common theme among all our selected authors was that all were striving for excellence, and all are “practicing” clinicians. A second look at the list also reveals the multidisciplinary nature of our team with family physicians, internists, cardiologists, radiologists, orthopedic surgeons, neurosurgeons, nutritionists, psychologists, physiologists, physiatrists, allergists, therapists, and athletic trainers, among others all contributing. Despite the charge of creating a concise book that included only “just the facts,” we were overwhelmed by the quality, and faced the unenviable position of editing a considerable amount of material. We tried to replace volume and detail with concisely written tables and algorithms where applicable. A review of any of the chapters will quickly bring the reader to the conclusion that this text is much more than “just the facts. We believe it does, as this book will be an excellent reference for review and for clinical reference in patient care settings. When we talked about dedicating the book we were all in agreement that this text should be for those members of our family who have supported us through- out the years; through the long days, the evening training rooms, the volunteer community events, and the Friday nights and Saturday afternoons at local sport- ing events. We especially want to thank our wives, Janet, Susan, Kathy, and Linda and all our children, Ryan, Sean, Brendan, Lauren, Stephen, Ryan, Caroline, Samantha, Matt, Shannon, Patrick, Matthew, and Danielle. We would additionally like to thank Darlene Cook for her vision and support, and Michelle Watt, our developmental editor at McGraw-Hill for keeping us on task.

The Part I exam outline consists of two independent dimensions or content domains discount hoodia 400mg jeevan herbals hair oil, and all test questions are classified into each of these domains proven hoodia 400 mg herbs for anxiety. Applied Sciences xxi xxii BOARD CERTIFICATION All Part 1 candidates received performance feedback in the form of scaled scores for each of these content domains. To allow performance in one section to be compared to performance in other sections, the section scores were scaled to fall between 1 and 10. A score of 1 would indicate that a candidate performed no better than chance, while a score of 10 indicates that a candidate answered all questions correctly in that section. According to psychometric data available to the Board following each examination, it is apparent that this year, as in previous years, the sections are not equally difficult for the group as a whole. Candidates in 2003 performed better in the Musculoskeletal Medicine section, while lower scores were recorded in Amputation and Rehabilitation Technology. THE PURPOSE OF CERTIFICATION The intent of the certification process as defined by Member Boards of the ABMS (American Board of Medical Specialties) is to provide assurance to the public that a certified medical specialist has successfully completed an accredited residency training program and an eval- uation, including an examination process, designed to assess the knowledge, experience and skills requisite to the provision of high quality patient care in that specialty. Diplomates of the ABPM&R possess particular qualifications in this specialty. THE EXAMINATION As part of the requirements for certification by the ABPMR, candidates must demonstrate satisfactory performance in an examination conducted by the Board covering the field of PM&R. The examination for certification is given in two parts, computer based (Part I) and oral (Part II). EXAMINATION ADMISSIBILITY REQUIREMENTS Part I Part I of the ABPMR’s certification examination is administered as computer-based testing (CBT). To be admissible to Part I of the Board certification examination, candidates are required to complete at least 48 months of ACGME-accredited postgraduate residency training, of which at least 36 months should be spent in supervised education and clinical practice in an ACGME-accredited PM&R residency training program. Part II Part II of the ABPMR’s certification examination is administered as an oral examination. At least one full-time or equivalent year of PM&R clinical practice, PM&R-related clinical fel- lowship, or a combination of these activities is required after satisfactory completion of an accredited PM&R residency training program. The clinical practice must provide evidence of acceptable professional, ethical, and humanistic conduct attested to by two Board-certified physiatrists in the candidate’s local or regional area. In rare instances in which a physiatrist is not geographically available, two licensed physicians in the area may support the candidate’s application for Part II. Additional information about the certification and re-certification examinations are provided in several brochures published by the ABPMR. The brochures are titled Preparing for the Computer-Based ABPMR Examination, Computer-Based Testing Fact Sheet, and Preparing for the ABPMR Oral Examination. Part I Examination The Board made the decision to implement computerized testing for the Part I certification exam because they felt it offered many advantages to examinees. These include access and BOARD CERTIFICATION xxiii conveniences, enhanced security, and cutting-edge technology (e. Computer-based testing (CBT) is the administering of an exam using an electronic multiple- choice question format. The ABPMR transitioned from paper-and-pencil exams to CBTs with the May 2002 cer- tification exam. The Part I exam is administered on an electronic testing system that elimi- nates the use of paper and pencil exam booklets and answer sheets. Candidates use a keyboard or mouse to select answers to exam questions presented on the computer screen. The time remaining and the number of the question currently being answered are visible on the computer screen throughout the exam. Computer based testing provides simple, easy-to-follow instructions via a tutorial to complete the exam. The ABPMR uses a simple, proven computer interface that will require only routine mouse or cursor movements, and the use of the mouse or enter-key on the keyboard to record the option chosen to answer the question. Examinees have the option of using a brief tutorial on the computer prior to beginning the actual exam. Time spent with the tutorial does not reduce your testing time, so they recommend that examinees take advantage of it. The tuto- rial is available at the beginning of each section of the exam. It includes detailed instructions on taking the computerized exam and provides an opportunity to respond to practice ques- tions.

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 buy discount hoodia 400 mg on line herbs near me, meaningful therapeutic relationships with their patients order hoodia 400mg free shipping herbalshopcompanynet. 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. However, as a civil case in California in 2001 shows, PCPs do face poten- tial punitive consequences from their inaction. Wing Chin was found guilty of committing elder abuse and recklessness for failing to ade- quately treat the chronic pain of one of his patients with opioid medications. These criminal and civil suits highlight potential new risks to physicians associated with managing patients with chronic pain, adding to the distress they already feel about prescribing this class of drugs. The Drug Enforcement Administration In addition to fears of legal action taken against them from the criminal justice system, PCPs also face the potential of investigation and punitive actions from the Drug Enforcement Administration (DEA). In Texas, which instituted a triplicate controlled substances prescription in 1982, schedule II opioid prescriptions dropped by 64% in the year following the policy change. Surveys of physicians regarding their prescribing patterns of opiate medications Olsen/Daumit 142 reveal that fear of DEA investigation is among the most frequently cited rea- sons for not prescribing opioids [30, 31]. Medical Boards Adding even further to the complicated melting pot of pressures, state medical boards create their own system of incentives and disincentives for PCPs in treating chronic nonmalignant pain with opioids. Since medical boards carry the responsibility and burden of reprimanding and sanctioning negligent physi- cians in each state, they carry a vested interest in the prescribing patterns of PCPs. State medical boards vary in how they carry out surveillance of physi- cians in this regard but in most states there is a mixed message given to PCPs – on the one hand, PCPs must treat pain adequately, using opioids if necessary, or face the consequences of potentially negligent practice but they must not overprescribe opioids or they face the consequences of potentially negligent practice. Joint Commission on Accreditation of Healthcare Organizations In recent years, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has on the behalf of patients actively become involved in the issue of pain treatment. Acknowledging the plight of pain sufferers and the importance of adequate pain treatment to the overall well-being of patients, the Joint Commission in 1999 announced that, as of the 2001 accreditation process, physicians were expected to assess all patients, both in inhospital as well as in ambulatory-based settings, for the presence and severity of pain and to address these complaints if present. In effect, JCAHO elevated pain to the status of the fifth vital sign alongside blood pressure and heart rate. Because failure to comply with these expectations could have dire conse- quences for the accreditation status of health care systems, PCPs working in these institutions now face added pressure from administrators to ensure that chronic pain is adequately treated without necessarily receiving guidance on how opioids fit into this. Pharmaceutical Companies Pharmaceutical companies have been in the business of manufacturing therapeutic opioid medications since before the formal beginning of the indus- try, but not until the introduction of Oxycontin had the issue of pharmaceutical marketing of opioid drugs to physicians garnered such media attention. Pharmaceutical company representatives frequent doctor offices on a daily basis, plying their wares but many PCPs find their presence a necessary evil. Restrictions have been placed on what these representatives can and cannot do in order to entice physicians to prescribe the particular medication they are Opioids for Chronic Pain in Primary Care 143 promoting. However, recent lay press articles document the aggressive marketing practices of Purdue Pharma, the manufacturer of Oxycontin. While many feel that these marketing tactics were excessive, they worked to convince large numbers of PCPs to prescribe Oxycontin. Beginning with its introduction in 1995, sales of Oxycontin skyrocketed and it quickly became one of the fastest selling drugs on the market. Lack of Clear Guidelines Since the early 1990s individual pain researchers and specialty organiza- tions have produced several disease-specific guidelines for the management of chronic nonmalignant conditions such as sickle cell anemia [19, 38–41].

However generic hoodia 400mg overnight delivery herbals summit 2015, we have never encountered a problem in clinical respects buy hoodia 400 mg line herbals on deck, since the most mobile joint of the body, the shoulder, can compensate for this defect. Treatment of displaced humeral shaft fractures: If (in children and adolescents. Ossification system of the elbow: The most important epiphyseal ossification center is that of the capitulum humeri, which can be seen on an x-ray around the age of four months. The epiphy- seal center of the radial head and the apophyseal center of the ulnar epicondyle appear around the age of five. The epiphyseal center of the trochlea, that of the ulna and the apophyseal center of the ulnar epicondyle appear – likewise together – between the ages of nine and c 12. Between the ages of 11 and 13, the centers gradually fuse with the metaphysis, concluding with the apophyseal center of the ulnar epi- ⊡ Fig. Fracturesof the elbow:aExtra-articular distal humerus: condyle, the epiphyseal center of the radial head and the epiphyseal The commonest of all elbow fractures is the supracondylar humeral centers of the ulna fracture (left). A fracture of the ulnar epicondyle (center) occurs more often in association with the elbow dislocation, while a fracture of the radial epicondyle (right) is a less common concomitant injury. Correct diagnosis is often a problem for olecranon fractures (right) are fairly rare unskilled practitioners, as evidenced by the numerous unnecessary side-comparing x-rays, which do not usually allow any conclusions to be drawn. Supracondylar humeral fractures typically occur in 5- to ▬ The biomechanics of the elbow, which, in the case of 10-year olds and account for approx. Fracture types The cross-sectional anatomy of the distal humerus is We distinguish between the following types (⊡ Fig. Even ▬ fractures in the area of the proximal end of the radius minor rotational deformities can lead to instability and (extra-articular), slipping of the distal fragment into a varus deviation. Almost all complications occurring after supra- condylar fractures are primarily iatrogenic in Normally, a line extending distally along the ante- origin. Diagnosis Clinical features A completely displaced fracture is usually accompanied Fracture types by extensive swelling of the elbow. In hyperextension Three types of fracture can be distinguished, depending fractures, the sharp proximal fragment is displaced an- on the degree of displacement in each case, according to teriorly into the brachialis muscle and subcutaneous tis- the most frequently cited Gartland classification. The sues, producing an anterior subcutaneous hematoma, or types most usually seen are an extension fracture with even penetrating the skin in the case of an open fracture. In most cases the Type I non-displaced, cubital artery is merely kinked over the proximal frag- Type II displaced but with preserved continuity of the ment. The same applies to the median nerve, which posterior cortex, most often shows a primary deficit [13, 53]. Signs of a rotational deformity include a rotation to enable a primary neuropathy to be differentiated from spur or a difference in the AP diameter between the a secondary, iatrogenic neuropathy. This includes the proximal and distal fragment on the lateral x-ray recording of unclear findings, which generally tend to be (⊡ Fig. We perform Doppler ultrasound only if the radial pulse is still not palpable after reduction. If no vascular Differential diagnosis signal is shown on the ultrasound scan then vascular revi- Supracondylar fractures must be differentiated from el- sion is indicated. The latter show a fracture line that crosses the growth plate in the Imaging investigations lateral projection. The whole supracondylar area shows extensive intra-ar- ticular hemarthrosis after a fracture. Two thick fat pads Treatment are located at the front and back between the fibrous and Conservative synovial layers of the capsule, resulting in a contrasting Type I: »fat pad sign« on the x-ray in the event of the intra-articu- Long-arm cast for 2–4 weeks, depending on the age of lar accumulation of fluid. For initially non-displaced fractures, those Standard AP and lateral x-rays are arranged only if no at greatest risk of displacement are those in which obvious deformity is clinically apparent. In order to avoid at least one of the two condylar pillars is completely unnecessary manipulations, the x-ray is recorded in this fractured. In this case, a check x-ray, without cast, is case with the arm in the most comfortable position. Classification of supracon- dylar humeral fractures: Since the rotational deformity and the resulting instability repre- sent the central problem in these fractures, the only distinction required in such cases is between fractures without (a, b) and frac- tures with (c, d) rotational deformities a b c d 501 3 3.