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Without a corset the patient collapses into extreme worn than the theoretically more correct completely rigid kyphosis and is unable to look straight ahead versions generic eurax 20 gm on-line. If there is only dynamic instability of the lumbar spine, short braces extending from the pelvis up to the bottom of the rib cage may suffice. These may be worn Patients with flaccid paresis with a substantial neurologi- only for situations where trunk stability is required (such cal component lack not only control over their extremi- as in some types of occupational therapy or school ). But even patients with pro- The efficacy of any corset used for neuromuscular nounced spastic tetraparesis and spasticity and hyperto- spinal deformities must be checked radiologically. To this nicity of the extremities will often show muscle hypotonia end, and ideally in the same session, general x-rays of the in the trunk, particularly the lumbar spine. The objective spine under load should be recorded, with and without of the trunk orthosis (corset) is to compensate for this the corset, with the patient seated or standing. The corset instability and stabilize the patients in an upright posi- should correct at least 25% of the curve. If the patients are straightened without an external Generally speaking, corsets may also be indicated in stabilizer, the spine will collapse into a scoliotic and/or patients with muscular dystrophy, although surgical cor- kyphotic position (⊡ Fig. These deformities will rection should be performed as soon as possible in these subsequently become fixed at bone level. Progression is certain, and the patient’s general Spinal deformities constitute another indication. The duration of corset use lioses or kyphoses or combinations thereof are not un- will depend on the therapeutic objective. Since the pri- common in patients with poor neuromuscular control of mary effect is to compensate for the action of gravity, it the trunk. The prevailing muscle tone indicates the direc- should only be used in the upright position. In such cases, gravity fear of muscle weakening should not be a primary con- constitutes an important pathological mechanical factor sideration in the use of trunk orthoses. The corset is not worn all day, thereby allowing This hinders their use and serves as an obstacle to im- sufficient muscle activity for maintaining strength. A better solution ly, the muscle strength has been impaired merely by virtue is a trunk orthosis that reduces the patient’s postural effort of the dynamic instability, and the patients have to make and facilitates, or even allows in the first place, balanc- the extra effort to withstand the effects of gravity.

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The Surgical Team For these operations to be done in a timely manner requires at least two experi- enced surgeons discount eurax 20gm amex, and up to four are preferable. The senior surgeon makes decisions regarding the adequacy of excision, which donor site areas will be taken, and how the skin will be meshed and where it will be placed. He or she also participates in excision, placement of the grafts, and application of dressings with assistance from the other surgeons. The anesthesia team and nursing team also play key roles in the actual performance of the operation. At our institution, the anesthesia team not only administers anesthesia, but also participates by holding the airway during position changes, turning on the air pressure for the Pitkin’s device, and irrigating the wounds with dilute epinephrine solution. The nursing staff has the responsibility not only for providing instruments and other equipment required to do the opera- tion but also for meshing the grafts. For excision of large burns ( 40% TBSA), we have found that two of the nursing staff should be scrubbed, with one providing instruments and another meshing the skin. TREATMENTS SPECIFIC TO ANATOMICAL LOCATION Particular anatomical regions require specific treatments. These issues should be considered and incorporated into the operative plan. Head and Neck The head and neck have an ample blood supply that enable it to resist invasive infection better than other parts of the body. It is also probably the most important area in terms of cosmesis and function (eyes, mouth). Since the face is so important cosmetically, sharp excision of eschar is not recommended in order to preserve any dermal and epidermal structures The Major Burn 243 FIGURE 3 Cosmetic units of the face. Application of sheet grafts should be in this distribution, if possible.

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Informed consent is the premise behind the widely used opioid contract which is a valuable aid in maintaining patients with a history or current problem with chemical dependency in chronic pain treatment purchase eurax 20 gm with mastercard. The degree to which addiction is voluntary is a very old debate recently revived. Evidence from basic science studies of the pathophysiology and pharmacology of both chronic pain and addiction, and from neuroimaging and molecular genetics suggests that both the cognitive and volitional capacities required for informed consent are diminished in patients with addiction and chronic pain to varying degrees. The behavioral phenomena that characterize SUD, To Help and Not to Harm 163 compulsion, obsession, loss of control, craving, and the continuation of sub- stance use despite negative, medical, psychological, and social consequences are understood from this perspective as symptoms of a brain disease [57, 80]. The neuropsychiatric correlates of these behaviors, neuroadaptation and sensi- tization, appear to diminish the authentic freedom and decisional capacity of the addicted individual as they pertain to informed consent. It is widely recognized that stress, sleep deprivation, anxiety, trauma, and depression or other psychological factors that often accompany pain and SUD may both lower the pain threshold and diminish decisional capacity and autonomy [1, 82]. The practical implication of these theoretical findings is that patients with a history of substance abuse or an active problem may enter into opioid con- tracts with good intentions but diminished capacity for informed consent. If aware of these limitations in the patient’s voluntarism, physicians can provide additional safeguards to protect the patient against relapse or development of addiction such as involving partners and family in treatment, dispensing only small amounts of medication, early and consistent collaboration with substance abuse experts, and most importantly establishing an open and trusting relation- ship in which patients feel safe expressing cravings, lapses, and temptations. Regarding minor infractions of the opioid contract as slips expected in a chronic and relapsing disease rather than intentional undermining of treatment allows both physician and patient to arrive at more constructive solutions. Physicians must also be vigilant about diagnosing and treating the common psychiatric conditions associated with chronic pain that can further reduce deci- sional capacity such as depression, anxiety and psychosis. A Harm Reduction Approach Physicians involved in the care of patients with active or historical SUD and chronic pain are confronted with a number of ethical dilemmas. The fol- lowing recommendations constitute a harm reduction approach to the care of patients with addiction and chronic pain. Harm reduction is a philosophy and a practice utilized in some segments of the addiction medicine community. It offers a means of managing many of the dilemmas patients with chronic pain and addiction present [86, 87].