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Gains in pain and activity frequency were comparable to those from similar CBT programs; changes in depression generic lynoral 100mcg overnight delivery, low at the outset, were modest, and there were none in self- rated disability. Although this is now a widely replicated model, and there are doubtless deficits in knowledge and strategies to be remedied among 284 HADJISTAVROPOULOS AND WILLIAMS chronic pain patients, the model cannot be extrapolated unquestioningly to populations of patients who are frequent users of health care and are signif- icantly distressed and disabled. Attending support groups over a 1-year period shows no enhanced treatment gains in terms of sick leave, function, and pain (Linton, Hellsing, & Larsson, 1997). Together the just cited studies suggest support groups may have a place as an adjunct approach among chronic pain patients, but provide evidence against reduc- ing the level of expertise and time and resources put into CBT group pain management programs. Commentary In 1992, Keefe and colleagues expressed widely held hopes that research us- ing larger sample sizes would demonstrate the “active ingredients” of CBT treatment packages; discover how to improve maintenance of treatment gains; and extend CBT to other patient groups, such as those with osteo- arthritis, rheumatoid arthritis, and sickle-cell disease. Meanwhile, extensive CBT programs have been subject to cost cutting, thereby reducing the quality and quantity of established treatment facilities. Research has been limited largely to small volunteer studies, making it particularly hard to model change in treatment (and maintenance after treatment) or to carry out stud- ies with sufficient sample size to do justice to the many interacting vari- ables affecting outcome. The questions identified by many clinicians and researchers (Turk, 1990), and to which some anticipate answers from large treatment studies or meta-analyses, are, “Which are the right and wrong patients? Meanwhile, no consistent findings have emerged from many component dismantling trials (see Morley et al. This is not so remarkable given that all investiga- tions are subject to local peculiarities of referral, funding, and acceptance and rejection criteria. We can, however, draw some practical suggestions from mainstream psychology: People with major depressive disorder are unlikely to engage or participate until they have more hope and sense of a tolerable future, so immediate treatment of depression is indicated; pho- 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 285 bias of groups or health care settings may preclude common methods and settings for delivery.

This is due in part to the increased efficiency and reduced costs demanded by managed care plans such as health maintenance organizations buy lynoral 100mcg low cost, as care for patients is shifted from physi- cians to other medical professionals, such as physician assistants and highly skilled nurses. Although the prediction of oversupply of physicians in some sub- specialties such as gastroenterology, medical oncology, and hema- tology is real, according to the Bureau of Labor Statistics the need for physicians will grow about as fast as the population. Also, the employment outlook for physicians will remain strong in rural and low-income areas. Department of Health and Human Services calls Health Professional Shortage Areas (HPSAs). More than 46 million people live in such areas in the United States, Medicine in the Twenty-First Century 87 54 percent of them in inner cities and 46 percent in rural areas. For example, in these areas children are still dying of diseases such as measles that should have been thoroughly eradicated by vaccination programs. People in the HPSAs also are more likely to suffer from high infant mor- tality, lead poisoning, tuberculosis, and AIDS. The changing demographics of the United States have also cre- ated a need for physicians who are conversant in other languages and knowledgeable of other cultures. In some large cities, physi- cians now treat a patient population that speaks dozens of differ- ent languages. Alternative Medicine Currently, about two in five Americans say that they use alterna- tive therapies when they are sick. The therapies that they seek include homeopathy, nutritional supplements, acupuncture, and meditation. Traditionally, the medical profession has dismissed alternative medicine as essentially voodoo medicine, rooted in superstition and mysticism. Faced with the fact that many of their patients are employing alternative medical strategies, more than half of the nation’s 126 medical schools, including prestigious institu- tions such as Harvard, Columbia, and Stanford, include some train- ing in alternative medicine. Medical students can now enroll in classes that introduce them to topics such as acupuncture, herbal medicine, and therapeutic massage. This is not to say that alternative medicine has completely entered the realm of acceptance. Instead, there is a new emphasis on subjecting alternative medicine to the traditional rigors of med- 88 Opportunities in Physician Careers ical research.

Even if the risk of and percutaneous epiphysiodesis on the longer side complications is lower with the shortening osteotomy shortly before completion of growth buy discount lynoral 100mcg on line. It should be borne in mind that the the healthy leg is much more problematic than one lengthening of the muscles in this situation is invari- in the diseased leg. Patients with for correcting fairly small differences is relatively un- poliomyelitis already have muscle power problems problematic, since the transcutaneous method rarely and only just manage to walk. Any lengthening pro- involves any complications, its morbidity is extremely cedure involves the risk of a deterioration in, or even low and no functional restriction is expected. Caution is required when assessing patients with ▬ Another important factor is the expected final length. This often involves a height gain of 25 cm or cedure than short people, and the wishes of the patient more. The desire to be taller is understandable in these should be respected particularly in this situation. Since the arms are almost always shortened ference is more than 8 cm, the lengthening must be as well as the legs, patients with lengthened legs and performed in stages. Consequently, the of more than 8 cm at a time in a given stage as the possibility of arm lengthening must also be consid- complication rate rises sharply above this level. Although many such lengthening procedures ▬ The leg length equalization should always be per- have been implemented worldwide on patients with formed at the site of the discrepancy (upper or lower dwarfism (particularly with achondroplasia), the leg). Let us assume that a patient has a leg length siderable, albeit temporary, psychological stress. Since a maximum height We also have experience with bilateral lengthening. The difference of 2 cm is acceptable for the knees, we rule that lengthening should not exceed 8 cm in each would only lengthen the femur in this case. We primarily lengthen ▬ If substantial differences of over 20 cm are anticipated, both lower legs and only secondarily both upper legs. If then one should consider very carefully whether the attempt has to be discontinued after the first stage of lengthening is appropriate at all.

Congenital idiopathic clubfoot The term talipes equinovarus is derived from the Latin word talipes (talus:ankle; pes:foot) and equinus (horse-like) purchase 100mcg lynoral with mastercard, and varus (inverted or adducted), and is exquisitely descriptive of the deformity. Anteroposterior (a) and lateral (b) radiographs demonstrating commonly in males, and occurs bilaterally in hip subluxation in a young child prior to ossification of the secondary center nearly 50 percent of all cases. If a second male child is affected, there is nearly a 400 times increase in incidence. At birth the deformity is readily recognized, although some feet are more rigid than others. It is the feature of rigidity that separates the deformity from postural intrauterine positioning. The components of rigidity are a forefoot adduction and supination, termed adductovarus, combined with inversion or supination of the hindfoot (varus) and equinus of the hindfoot (fixed plantar flexion) 29 Congenital idiopathic clubfoot (Figures 3. Even with manipulation, the foot cannot be reduced into a normal position. At the present time the exact etiology is obscure, but there are several theories, none fully substantiated, that are embraced by many orthopedic surgeons. One group believes that the clubfoot is a germ plasm defect, in which the talus never develops into a normal size and shape, and that all other deformities seen are secondary to the primary talar deformity. The second school of thought centers on the clubfoot being a neuromuscular disorder, not previously described, which results in all observed deformities occurring as sequelae of Figure 3. Anteroposteriorradiograph of an 8-month-old child with a “late neuromuscular imbalance. Regardless of which of the theories is eventually proven correct, it is clear (a) that the talus is always deformed, with a foreshortened talar neck that is always medially and plantar deviated. This typical deformity of the talus has been visualized in nearly all stillborn cases who have clubfeet, and in all operative cases to some degree.