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Upsloping ST segment depression that is probability of CAD becomes nearly 70% proven xalatan 2.5 ml treatment xanthelasma eyelid, a much greater than 0 trusted 2.5 ml xalatan treatment tracker. Chest pain occurring with exercise typical of between 1 and 2 mm of ST depression, her posttest angina probability of CAD still is less than 20%, and little 6. Abnormal 1-min HRR or 3-min systolic BP PREDICTION OF SEVERITY OF CAD response 9. ST-segment depression in recovery only A suggestive or positive written report may be used to 10. Normalization of abnormal ST-segments/ further manage patients by predicting the severity of T-wave inversion CAD. The following are important exercise to at least 85% of predicted HRmax test predictors of severe CAD (Goldschlager, Selzer, d. ST depression beginning at low workload, <5 METS ischemia based on the above criteria. Downsloping configuration (99% predictive of the patient is not on B-Blockers or has CAD) or ST elevation chronotropic incompetence. Low workload ability, <5 METs Physicians can use the results of the exercise test to i. Exercise induced hypotension guide them in the management of their patients. Chronotropic incompetence approach should include a probability statement of k. Anginal symptoms CAD and a prediction of severity of CAD, prognosis ST depression only at high workloads (HR >160 bpm of the likelihood of future adverse events in a patient or changes only after Stage IV—Bruce protocol at based on the exercise treadmill score (ETS), and exer- 12 min) correlates with a low mortality and good prog- cise prescription. In fact, the ability to exercise >13 METs has a good prognosis regardless of the EKG changes. Many cardiologists recommend repeating the PROBABILITY OF CAD exercise test in 6 months without further workup in these patients (Goldschlager, Selzer, and Cohn, 1976). The predictive value, however, depends on the preva- EXERCISE TREADMILL SCORE lence of CAD in the population tested. It is therefore imperative to determine a pretest probability of CAD This tool supports the above concepts by assigning a in a patient, and then use the results of the treadmill to score to determine prognosis (Mark et al, 1987; 1991): determine a new posttest likelihood. Exercise stress testing has the greatest value in those individuals who Treadmill score = Exercise duration (min) − 5 × ST have a pretest probability between 20 and 80%. The ET score is thus valuable for prognosis and should be cal- culated in all patients undergoing CAD evaluation. REFERENCES ACC/AHA Guidelines for Exercise Testing: A Report of the EXERCISE PRESCRIPTION (ACC/AHA GUIDELINES American College of Cardiology/American Heart Association FOR EXERCISE TESTING, 1997; AMERICAN Task Force on Practice Guidelines (Committee on Exercise COLLEGE OF SPORTS MEDICINE, 2000a) Testing). American College of Sports Medicine: Guidelines for Exercise The exercise test can assist in writing the exercise pre- Testing and Prescription, 6th ed. A symptom-limited test establishes a base- Williams & Wilkins, 2000a, pp 22–32. American College of Sports Medicine: Guidelines for Exercise line fitness level and establishes a parameter for Testing and Prescription, 6th ed. The conditioning range for most adults to tions 2003: Physical activity/exercise and diabetes mellitus. American Heart Association Scientific Statement: Exercise stan- dards for testing and training. SPECIAL CONSIDERATIONS Califf RKM, McKinnis RA, McNeer M, et al: Prognostic value IN ATHLETES of ventricular arrhythmias for suspected ischemic heart dis- ease. Diamond GA, Forrester JS: Analysis of probability as an aid in exchange to establish a VO2 max, is most often the clinical diagnosis of coronary artery disease. It is not uncom- Ellestad MH: Stress Testing: Principles and Practice, 4th ed. AV blocks, right axis deviation, ventricular hypertro- Evans CH, Froelicher VF: Some common abnormal responses to phy with repolarization abnormalities, or incomplete exercise testing: What to do when you see them. Evans CH, Harris G, Ellestad MH: A basic approach to the inter- normal variants known as the athletic heart syndrome pretation of the exercise test. Evans CH, Karunarante HB: Exercise stress testing for the family Interpretation of the exercise test in this population physician. Am Fam Physician incorporates the same criteria as the general popula- 45:121–132, 1992a.

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Due to a lack of mobility purchase xalatan 2.5 ml otc bad medicine, and hence of compensa- Grice arthrodesis is minimal 2.5 ml xalatan with mastercard symptoms multiple myeloma. Maintaining mobility is therefore favorable Structural deformities in functional feet, especially if sensation is not normal. A Structural deformities in primarily flaccid locomotor disor- muscle transfer procedure to replace the absent plantar ders and muscular dystrophies are shown in ⊡ Table 3. Although good results have been Structural deformity of the foot caused by reduced or described, our everyday experience with our patients has absent muscle activity. The shortening of the Achilles tendon represents a Definition logical alternative. However, this procedure is reputed to A contracture of the triceps surae muscle is present, produce poor results. Although it can prove helpful in regardless of the muscle activity and power, which extreme cases, the chances of a good result in neuro-or- prevents dorsiflexion even with a flexed knee. This must be prepared difficult for the body to keep in balance over the flaccid leg. Otherwise the only bilizers that would have to keep the foot on tiptoe are also option for protecting the knee from giving way in flexion insufficient. The foot skeleton becomes deformed and fixes is by supporting it with the hand ( Chapter 4. The ability to A slight hyperextension of the knee of up to 5° is 3 walk and stand can be further impaired as a result. Ideally, the hyperextension should be permits weight-bearing without deformation of the foot prevented indirectly by a corresponding orthosis for the skeleton. If a functionally disruptive contracture is pres- lower leg and foot with an integrated heel. An overcorrection will lead to a pes calcaneus position with corresponding flex- ion at the knees and hips, thereby compromising walk- ing and standing. If the knee and hip extensors are not available for compensation (as in muscular dystrophies), a slight overcorrection will result in the loss of the abil- ity to walk and stand. Since the lengthening procedure does not need to take account of the muscle power, it can be implemented in the form of tendon lengthening. One surgical technique for correcting the equinus foot in flaccid paralyses is the rearfoot arthrodesis according to Lambrinudi (⊡ Fig. This procedure is risky to the extent that dorsiflexion is not blocked at the ankle. If the knee and hip extensor muscles are not strong enough to compensate for the lack of power in the triceps surae, a crouch gait will result. The equinus foot is an important aid to stabilization during standing and walking, particularly in muscu- lar dystrophy patients and patients with post-polio syndrome. A slight case of equinus foot blocks the upper ankle and prevents dorsiflexion. As a result, the knee is indirectly ex- tended and the patient is able to remain upright passively ⊡ Fig. Patient with left-sided poliomyelitis after a dorsally extending talar osteotomy (Operation according to Lambrinudi) to (»plantar flexion – knee extension couple«, chapter 4. Since dorsiflexion is not blocked at Neither orthosis management nor an operation is indi- the ankle by this procedure and the extensors at the knee and hip are cated to correct this type of equinus foot. On the contrary, not strong enough to compensate for the lack of power in the triceps a foot with free dorsiflexion should be secured conser- surae, a crouch gait will result ⊡ Table 3. Structural deformities in primarily flaccid locomotor disorders and muscular dystrophies Deformity Functional benefit Functional drawbacks Treatment Equinus foot Knee extension Dynamic instability due to small Functional orthosis (in equinus foot) weight-bearing area Cast correction Deformation of the feet Tendon lengthening (beware of overcorrection) Clubfoot Compensates for Walking/standing aggravated Functional orthosis increased external Tendon lengthenings rotation of the leg Arthrodesis 439 3 3. Regular stretching of the triceps surae by the physical therapist or splint treatment (possibly with a postural splint) is indicated for preventing severe cases of equinus foot that interfere with standing and walking. The alternative options of a functional orthosis in an equinus foot position or surgical lengthening of the con- tracted muscle apply only to patients with a pronounced contracture of this muscle who are able to walk. In all cases, a slight residual equinus foot position is needed for functional purposes.

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The editorial team has the responsibility of communicating with the author purchase xalatan 2.5 ml with amex treatment keratosis pilaris, and the external reviewers have the responsibility of ensuring that the external review process is rigorous and expeditious effective xalatan 2.5 ml medicine assistance programs. When you send your paper to a journal, there are usually two levels of review. The first is the internal peer review by the editorial team to decide whether your paper is the type of article that they want to see in their journal and, if so, whether 121 Scientific Writing it is of an adequate standard to be sent out for external review. Editors have the ultimate responsibility of selecting papers that will appeal to the journal’s readership. At the BMJ, about half of the submitted papers are rejected in-house by the editorial committee3 and at JAMA 42% of papers are rejected without external review. Each paper is sent to only two or three reviewers but this may vary from journal to journal. The areas that reviewers are often asked to comment on are shown in Box 5. In addition, many journals ask reviewers to give a quality or priority ranking to various aspects of the paper. If the comments from two reviewers differ markedly, the editor will often ask for comments from an arbiter reviewer. The arbiter reviewer may be sent the prior review comments and asked to comment on both them and your paper. In this way, the integrity of the research, the quality of the journal and the development of the discipline are a combined responsibility of the editor, the reviewers, and the authors. Although letters from the editor to the reviewers often stress the confidential nature of papers under consideration, it is acceptable for external reviewers to pass papers on to colleagues for review. Thus, external reviewers are not always required to treat the papers sent to them with confidentiality. It is common practice for senior researchers to ask junior staff to review and comment on papers. In fact, editors often ask reviewers to do this if they do not have time to complete the external review themselves. However, to maintain standards, it is important that senior researchers supervise the review and approve the comments made. Once the editorial committee receives the reviewers’ comments, they classify the paper into one of several categories as shown in Box 5. Papers may be classified as unacceptable for publication on many grounds including poor science or reporting, inappropriate length, non-original results or material that is not appropriate for the journal. Editors are usually quite explicit in their correspondence about the reasons for their decisions. As such, it is a confidential consultancy between the reviewer and the journal editor. In a study of papers sent out to 252 external reviewers, 123 Scientific Writing less than 6% of the reviewers were correctly identified by authors. This left reviewers free to make whatever criticisms they felt necessary. The editor then forwards the comments to the authors without the reviewers being directly accountable. This closed review system often comes under criticism, especially when authors feel that their manuscripts have been unfairly treated or even plagiarised. Interestingly, identification had no effect on the quality of the feedback received, on recommendations regarding publication, or on the time taken for the paper to be returned to the journal. Despite the finding that this system was not detrimental to the quality of reviews, this type of open review is rarely conducted and anonymity is usually retained. In an attempt to remove any bias due to lack of anonymity of authors to the reviewers, the Medical Journal of Australia conducted a trial of removing authors’ names from papers sent out for external review. Once the paper was accepted for publication, the author and the reviewers were asked to consent to both the paper and the critical feedback being posted on the internet. An evaluation suggested that this open review system had some benefits such as increasing the fairness of the system and increasing the depth of feedback as a result of a wide range of readers posting their comments on the website.

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We are also grateful to numerous individuals who assisted us with this project buy xalatan 2.5 ml mastercard symptoms uterine cancer, especially Linda Sutherland at the UCSD School of Medicine buy xalatan 2.5 ml nature medicine. We would also like to thank our families who are always there for us and whose understanding made this project possible. MSW would like to thank his wife, Anne, and his two sons, Zachary and Dominick. PSS would like to thank his wife, Nancy, his parents, and his children, Alyssa, Dylan, and Rachel, for their unyielding support and for taking the pain out of his life. Section I TEST PREPARATION AND PLANNING ing the first 5 years of the examination system. Abram, MD specialty certification by their respective boards, not by the ABA, on successful completion of the examination. SUBSPECIALTY CERTIFICATION With the expansion of the examination system to EXAMINATION IN PAIN MEDICINE diplomates of the other two boards, there was a broaden- ing of the scope of the examination. Question writers and The American Board of Anesthesiology offers a written editors from Neurology, Psychiatry, and PM&R were examination in pain medicine designed to test for the added to the examination preparation process. Although presence of knowledge that is essential for a physician previous examinations included material from all aspects to function as a pain medicine practitioner. Certification of pain management practice, the infusion of new expert- awarded by the ABA on successful completion of the ise produced a more diverse question bank. For nation should, and does, contain information from all that reason, the ABA offers a pain medicine recertifica- of the disciplines involved in the multidisciplinary treat- tion examination as well. The areas of knowledge that are tested can The examination required for the Certificate of be found in the ABA Pain Medicine Certification Added Qualifications in Pain Management was initially Examination Content Outline. This document is revised offered in 1993 by the ABA, 1 year after the periodically and can be found on the ABA web site, Accreditation Council for Graduate Medical Education http://www. An approximation of the distribu- approved the first accredited pain fellowship programs. The A-type question is a the 1998 exam, ABA diplomates were required to com- “choose the best answer” format with four or five possible plete an ACGME-approved pain fellowship. The K-type question contains four answers with of the certification process has recently been changed to five possible combinations of correct answers: Subspecialty Certification in Pain Medicine. All are correct physicians from these specialties may be admitted to the examination system on the basis of temporary criteria The ABA certificates in pain medicine are limited to similar to the process in place for ABA diplomates dur- a period of 10 years, after which diplomates are required 1 Copyright © 2005 by The McGraw-Hill Companies, Inc. X Neuroanatomy and function 10% Then follow special problems (Sections XVII–XXXI) XI–XXV Pain states 20% concerning treatment of pain in specific populations, XXVI Diagnosis and therapy 20% for example, pregnant patients, children, and the elderly, XXVII Pharmacology 10% XXVIII Pregnancy and nursing 5% and in critically ill or severely injured patients in a crit- XXVIX Pediatrics 5% ical care setting. Finally there are sections on ethics and XXX Geriatrics 5% record keeping. A XXXII Ethics 5% XXXIII Record keeping, controlled useful source is the Core Curriculum for Professional drugs, quality assurance 5% Education in Pain, published by the International 100% Association for the Study of Pain. It is very useful, how- ever, in that it emphasizes the important aspects of each area of study, and provides concise information about to pass a recertification examination. The recertification each target area as well as extensive bibliographies for process uses the 200-question certification exam. The latest version is the second edition, success rates for the pain medicine examination through published in 1995. Recertification — — — — 63% 75% It is reasonable to use comprehensive textbooks as a study source, keeping in mind that, by definition, infor- mation is somewhat outdated by the time a large text- PREPARING FOR THE EXAM book is printed. While the examination tends not to use extremely new findings, there is an effort to keep infor- A reasonable first step in the study process is to identify mation current, particularly if there are strong data from areas of weakness. The first nine sections cover various plement the use of textbooks with recent review articles, body regions. One might begin with a review of the top- particularly for topics in fields that are changing rapidly, ographical anatomy and imaging techniques, followed such as the basic sciences related to pain. These are by a review of the more common regional block tech- available through medical literature search instruments, niques used for pain management. Keep in mind that the such as Medline, which can be limited to English lan- exam covers acute pain management as well as chronic guage, review articles, and, where appropriate, discus- and cancer pain, and anesthetic techniques begun in the sions of human subjects or patients. Often a combina- Section X, which lists a number of aspects of neu- tion of both sources results in the most effective reten- roanatomy and neurophysiology, pain mechanisms, and tion. Participation in pain medicine review courses the pathophysiology of painful conditions. Such courses Sections XI through XXV form a comprehensive list are offered by the American Pain Society, the of pain states.

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