By R. Muntasir. University of Dubuque.

With well over 2000 letters submitted every year discount 35 mg actonel mastercard medicine ball slams, we sometimes have to make difficult editorial decisions purchase actonel 35 mg line medications you can give dogs. On the basis of the recommendations of the reviewers and the Editorial Office, it was not accepted. Both reviewers raised concerns regarding the study design, analysis, and interpretation of the data. We hope that you can use their comments to improve your manuscript for submission to another journal. The further reports of the referees are enclosed and we hope that you will find them helpful. When evaluating whether a manuscript can be accepted for publication, the Editorial Office must consider several aspects such as scientific value, interest to readers, and space in the journal. Unfortunately, based on these factors and despite its scientific quality, your paper cannot be accepted for publication. We have now received the reviewers’ reports on your manuscript and enclose these for your information. However, if you would like to revise your manuscript to address the reviewers’ comments, we will resubmit it for review and will be happy to give it further consideration, although we cannot promise publication. Solving these sorts of problems usually involves some serious rewriting and may involve further data analyses. If the comments relate to style and presentation, you would be wise to spend some time fixing these up before you reformat your paper for a new journal and resubmit it. However, after three consecutive rejections, it is perhaps prudent to completely reassess your whole approach. Stephen King12 Once you have returned a revised paper to the journal, the editorial committee will consider the new version and your replies to the external reviewers’ comments. At the BMJ, papers that are thought to merit publication at this stage are passed on to a very appropriately named “hanging committee”. This committee is named after the committee at the Royal Academy in London that decides which pictures to hang in the summer exhibition each year. The hanging committee, which is made up of practising clinicians, statisticians, and medically qualified editors, makes the final decision about publication and may often ask for further revisions. Editorial decisions may be made on many factors of which the external reviewers’ comments are just one part. When a journal has a low publication rate, many papers have to be rejected. In the end, editors are likely to publish new, proactive, and interesting findings even if validity is in doubt, whereas papers that are more mundane have to have exceptional methods to even be considered. In addition, external reviewers may pass on confidential comments that contribute, rightly or wrongly, to editorial decisions and journals may lean heavily towards accepting papers that are likely to be cited regularly. It is a 132 Review and editorial processes matter of bread and butter for the editors. If the impact factor of the journal goes up then the quality and quantity of submissions also goes up, but if the impact factor goes down, then the good papers go elsewhere. You may find that the reviewers’ comments are not too damning, but that the editor has made his own decision to reject the paper anyway. Alternatively, the reviewers may have suggested fundamental changes to your paper, but the editor may be interested in publishing it. Publishing is essentially a competitive sport and journals often reject the majority of papers that they receive. It pays to be philosophical and to be prepared to accept the vagaries of the editorial system. If you think that you have an important new finding, you can ask the editor to expedite the review process or give you a rapid response on a publishing date. In this way, you may be able to fast track the publication of your results, although this doesn’t happen often. If your paper is rejected or if you feel that the reviewers have overlooked or misunderstood something important, you can appeal against the editorial decision by writing a letter stating your case. It is rare that the decision will be overturned, but it has been known to happen. It is also possible for a paper to be formally accepted by a regional editor who sends you a letter of acceptance, and then be rejected at a later date by the editor-in-chief, although this very rarely happens. Most editors receive more papers than their journal could ever publish and take the pragmatic view that you will get your work published somewhere if it is good enough.

A 1985 review of TABLE 18–5 Epidural Abscess versus Hematoma spinal and epidural abscesses indicated that the inci- ABSCESS HEMATOMA dence of epidural abscess did not rise from 1965 to Time course Insidious and slow Acute and abrupt 1985 purchase actonel 35mg line treatment brown recluse bite, despite the increased use of epidural anesthe- Hours to days Minutes to hours sia/analgesia during that period cheap 35 mg actonel with visa medicine 5e. Relative contraindi- Typical symptoms Starts with local back Starts with local cations to epidural placement include local infection pain and tenderness back pain and percussion tenderness to at the intended insertion site and sepsis (Table 18–5). These occurs with services must be seamlessly integrated into the hospi- lumbar lesions Fever and leukocytosis tal infrastructure to be effective. In Sepsis our experience, once established, an effective acute Mental status changes pain management service becomes an expected part Diagnosis MRI with gadolinium MRI with gadolinium of perioperative patient care. This can with medical treatment decompression be accomplished only with close patient surveillance. Development for an anesthesiology-based postoperative pain management service. Acute pain anesthesia and analgesia on coagulation and outcome management in adults: Operative procedures, quick after major vascular surgery. Regional anesthesia in agement service with regional anesthesia: How to the anticoagulated patient defining the risks. Epidural anal- gesia with intravenous morphine patient-controlled Yeager MP, Class DD, Neff RK. Epidural anesthesia and analgesia: Postoperative outcomes measures after analgesia in high-risk surgical patients. Alpha2-adrener- 19 INTRATHECAL THERAPY FOR gic agonists for regional anesthesia. Incidence of neuro- Just as a superhighway provides discrete travel lanes logic complications related to thoracic epidural for a host of different vehicles, the spinal cord catheterization. Despite our expanding knowledge of the receptors and com- Liu S, Carpenter RL, Neal JM. Epidural anesthesia and pounds that govern these signals and the increasing analgesia. Effects of perioper- Our delivery methods are also less than ideal, and, ative analgesic technique on rate of recovery after despite nearly a quarter century of experience, use of colon surgery. OTHER AGENTS IN USE INTRATHECAL AGENTS In an attempt to improve analgesia and reduce side effects and despite the lack of standard practice MORPHINE guidelines that would provide important information on neurotoxicity, drug stability, pump compatibility, Preservative-free morphine is the only agent approved and drug efficacy, clinicians are also administering by the US Food and Drug Administration and by man- the following analgesics intrathecally (Figure 19–1). These (Versed) (rarely used in the United States) numbers should be modified according to clinical α2-Adrenergic agonist: clonidine (persisting side practice. Switch to lipophilic opioid + adjuvant or *Under US Food and Drug Administration evalu- Switch to an investigational agent ation. Clonidine is mod- PRIALT is under investigation for treatment of neuro- erately lipophilic. Bupivacaine or clonidine with morphine, hydro- Acetylcholinesterase inhibitors, such as neostigmine. Intrathecal meperidine may erode pumps but offers combination opioid/local anesthetic relief, intermediate solubility, and high-concentration stability. EFFECT OF SPINAL OPIOIDS Intrathecal bupivacaine may cause seizures, cauda equina syndromes, or prolonged sensory deficits. At 1 year, the steroid group had Pruritus (tolerance can develop) marked reduction in pain. Reduces the cost of treatment Is minimally invasive because it does not involve THE CLINIC implanting a pump Carries a low risk of infection (the risk of infection The clinic’s basic resources must include: increases over time) A health care professional whose work is dedicated to implant coordination, patient education, and guiding the patient through the process. This person CONSTANT-FLOW-RATE PUMP has a role in: The preoperative screening trial This implanted titanium pump has two hollow cham- Surgical implantation bers divided by a bellows: Pump programming Freon is sealed in one chamber; the other is filled Pump refills percutaneously with the pharmaceutical via a self- Long-term patient management sealing septum. Dealing with adverse events When the drug reservoir is full, the Freon is com- Multispecialty access (including psychological con- pressed into a liquid state. A major psychopathology Those with neuropathic pain (caused by damage to A mood disorder the nervous system and described as burning, tin- The potential for self-harm gling, shooting, etc) are less likely to gain relief from Dementia intrathecal opioids than patients with nociceptive pain Anxiety (mediated by dispersed receptors in cutaneous tissue, Catastrophizing bone, muscle, connective tissue, vessels, and viscera). An unusually high degree of distress Addictive issues Sleep disturbances INCLUSION CRITERIA Conflicting motives and expectations The patient should have progressed through an accepted pain treatment continuum (ie, the World SCREENING TRIALS Health Organization ladder). The existence of side effects that would preclude A screening trial was successful. RELATIVE EXCLUSION CRITERIA EPIDURAL DRUG DELIVERY Emaciation Screening with epidural infusion involves a tunneled Ongoing anticoagulation therapy or percutaneously placed epidural catheter and per- Child awaiting fusion of epiphyses mits a trial to extend for days or weeks. Percutaneous Approach The STAATS (Simple Tunneling Approach and Technique Securing Catheters) method (see Figure MANAGING SYSTEMIC OPIOID USE 19–2 for an illustrated description of this technique).

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Depressed persons have also been found to use more of other types of health services than nondepressed persons [30 buy actonel 35mg cheap medicine 031, 35 purchase 35 mg actonel visa medicine 5325, 59, 60], further increasing the economic costs. Depression has been shown to exert a negative influence on health in diverse ways, including inhibiting recovery following hip fracture surgery, increasing the risk of physical decline [62, 63], and increasing the risk for mortality [64, 65], and may lead to unwarranted changes in medications and overmedication due to the amplification of symptoms that depression may cause [66, 67]. Depression is also associated with poor treatment adherence, which may adversely affect treatment and health status. Enabling individuals with RA to main- tain VLAs or to maintain psychological well-being after VLA disability may avert some of the negative effects that appear to be associated with VLA disability. Medical treatment prescribed for RA, whether analgesic, disease-modifying antirheumatic drug (DMARD), or referral for surgery, is often prescribed in response to functional declines or to maintain function by alleviating pain, limiting damage, or replacing joints. In spite of these best efforts, func- tional impairments may continue to develop or worsen. Thus, it becomes clinically helpful to know that functional declines may create a risk for poor psychological outcomes for a patient. Awareness of worsening functional status can give the physician a cue to ask specific questions about function or activity losses. Answers to those questions may serve as cues for referrals for intervention. Katz 54 Intervention point Intervention point Disability Health status Functional limitations Basic activities Psychological status Difficulty in activities of Pathology Restrictions in basic daily living (e. Extension and modification of the Verbrugge and Jette model of disablement showing points of intervention. The individual may be able to make behavioral changes to lessen the impact of functional limitations in order to maintain activities (i. Such behavioral changes might include making modifications in the way activities are performed, replacing activities, or pacing oneself. Escalante and Rincon suggest that medical therapies can intervene at different stages in the disablement process in RA. Medications may affect pathology or impairment, joint surgery may reduce impairment and functional limitations. Disability and Psychological Well-Being 55 the type of activity affected. Any intervention undertaken to increase behavioral adaptation would need to take such variation into account. Physical or occupa- tional therapy or vocational rehabilitation may assist in this process. Certain environmental and social factors may also affect the pathway from functional limitations to disability. For example, assistive devices are used relatively frequently and appear to be quite efficacious in reducing or resolving many functional limitations [71–73]. Having adequate help or personal assis- tance might also allow an individual to maintain activities. For example, having someone to drive her to a store, which has scooter-type shopping carts might enable an individual to continue to do her own shopping. Home, community, and workplace modifications may enable individuals with functional limita- tions to continue to perform activities; on the other hand, workplace or com- munity characteristics may also create barriers to individuals with functional limitations, and hasten the transition from functional limitation to disability. Therapeutic factors may lessen or delay the progress from functional limitation to disability. Through physical therapy, individuals may be able to maintain enough strength and range of motion in their joints to get around their community on their own. Finally, some individuals may have demographic or psychological characteristics that predispose them to the development of disability or to being able to maintain activities. For example, married individu- als may be better able to enlist help than those who live alone, which would enable them to maintain valued activities. Individuals who are optimistic by nature or exhibit a greater degree of self-efficacy may also be better able to main- tain activities [75, 76]. Conversely, individuals with low levels of education or who live alone may have few resources to draw upon to maintain activities. The second intervention point is between disability and psychological status.

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Hoaglund FT buy generic actonel 35 mg on line medications prescribed for ptsd, Healey JH (1990) Osteoarthritis and congenital dys- acetabuloplasty cheap actonel 35 mg free shipping medicine news. J Pediatr Orthop 11: 676–8 plasia of the hip in family members of children who have congeni- 68. Pravaz CG (1847) Traité théorique et pratique des luxations congé- tal dysplasia of the hip. Rombouts JJ, Kaelin A (1992) Inferior (obturator) dislocation of S, Terjesen T (2002) Universal or selective screening of the neona- the hip in neonates. Hopf A (1966) Hüftverlagerung durch doppelte Beckenosteoto- Zielhuis GA, Kerkhoff TH (2005) The natural history of develop- mie zur Behandlung der Hüftgelenkdysplasie und Subluxation bei mental dysplasia of the hip: sonographic findings in infants of 1-3 Jugendlichen und Erwachsenen. J Bone Joint Surg (Br) 43: 518–37 » The outlook in Perthes can be very grim, 72. Schoenecker PL Anderson DJ, Capelli M (1995) The acetabular response to proximal femoral varus rotational osteotomy. Segal L, Boal D, Borthwick L, Clark M, Localio A, Schwentker E (1999) Avascular necrosis after treatment of DDH: the protective Hip disease occurring during early childhood and caused influence of the ossific nucleus. J Pediatr Orthop 19: 177–84 by impaired circulation in the femoral head. Siebenrock KA, Leunig M, Ganz R (2001) Periacetabular oste- the ischemia is not known. J Bone Jt Surg Br 83: 449–55 Synonyms: Childhood aseptic necrosis of the femoral 75. Siebenrock KA, Schoeniger R, R G (2003) Anterior femoro-acetabu- head, Perthes disease, osteochondritis deformans lar impingement due to acetabular retroversion. Spitzy H (1923) Künstliche Pfannendachbildung, Benutzung von Knochenbolzen zur temporären Fixation. Z Orthop Chir 43: Historical background 284–94 The disease was described almost simultaneously, in 1910, by G. Staheli LT, Chew DE (1992) Slotted augmentation in childhood Perthes in Germany, J. Sutherland DH, Greenfield R (1977) Double innominate oste- Etiology otomy. Suzuki S, Kashiwagi N, Kasahara Y, Seto Y, Futami T (1996) Avas- While the etiology of Legg-Calvé-Perthes disease is not cular necrosis and the Pavlik harness. J Bone Joint Surg (Br) 78: known, numerous studies have highlighted various fac- 631–5 tors that play a role in the development of the illness. Eine Sam- ▬ Vascular supply: Angiograms and laser Doppler flow melstatistik des Arbeitskreises Hüftdysplasie. Enke, Stuttgart (Bücherei des Orthopäden, Bd 21) measurements in patients with Legg-Calvé-Perthes 82. Toennis D, Behrens K, Tscharani R (1981) A modified technique disease have shown that the medial circumflex artery of the triple pelvic osteotomy: Early results. J Pediatr Orthop 1: is missing or obliterated in many cases and that the 241–9 obturator artery or the lateral epiphyseal artery 83. Tönnis D, Heinecke A (1991) Diminished femoral antetorsion syn- Increased intra-articular pressure: Animal experiments drome: A cause of pain and osteoarthritis. J Pediatr Orthop 11: have shown that an ischemia similar to that in Legg- 419–31 Calvé-Perthes disease can be generated by increasing 85. Clin Orthop 281: 63–8 tion of transient synovitis of the hip does not appear to 86. Tucci JJ, Jay Kumar S, Guille JT, Rubbo ER (1991) Late acetabu- lar dysplasia following early successful Pavlik harness treat- be a precursor stage of Legg-Calvé-Perthes disease as ment of congenital dislocation of the hip. J Pediatr Orthop 11: the increased pressure resulting from the effusion in 502–5 transient synovitis does not lead to vessel closure. Thieme, Stuttgart Intraosseous pressure: The measurement of intraos- 88. J Bone Joint Surg Br 84: 339–43 the venous drainage in the femoral head is impaired, 89. Wagner H (1965) Korrektur der Hüftgelenkdysplasie durch die causing an increase in intraosseous pressure. Wedge JH, Munkacsi I, Loback D (1989): Anteversion of the femur and idiopathic osteoarthrosis of the hip.

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