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By C. Rozhov. University of Illinois at Chicago.

Within this perspective proven tadacip 20mg, act utilitarianism is focused solely on the ends of action purchase tadacip 20 mg otc, whereas rule utilitarian- ism advocates that the greatest good should be achieved by following pre- scribed rules (Sparks order tadacip 20mg without prescription, 1991) purchase tadacip 20 mg online. As such safe tadacip 20mg, the minimization of pain (and maximi- zation of happiness) would be an important goal of this approach. Rule utilitarianism differs from deontology because of its focus on consequences. This perspec- tive does not focus on the consequences or means of action but is primarily 12. Kluge (1999) stressed, for instance, the importance of acknowledging the functional em- bedding of all persons in their social contexts and attempting to reach reso- lutions on the basis of consensus and cooperation. Nonviolence is fre- quently emphasized within this perspective, and empathy (e. In other words, our actions must be guided by a sense of commit- ment to another person. Although it has been argued that, ideally, codes of ethics should provide a balance of theoretical ethical orientations (e. That is, they tend to provide rules without conceptual justification or explanation. A more balanced approach would allow one to outline deontological expectations while at the same time pro- viding a teleological rationale for ethical behavior. Such an approach would enhance the educational value of codes of ethics, which would be impor- tant because, although pain researchers and clinicians are knowledgeable in their fields, many do not have equivalent expertise in ethical philosophy. The values behind good ethical conduct are outlined remarkably well in the code of ethics that has been adopted by the Canadian Psychological As- sociation (CPA, 2000). Although many codes emphasize important ethical principles, the CPA code provides detailed and elaborate justifications for these. Specifically, the CPA code stresses the importance of dignity of per- sons, stating that each person must be treated primarily as a person or an end/in him or herself (as opposed to means to an end—e. The greatest responsibility is to those who are in a more vulnerable position (e. Clinician and researcher obligations linked to consent, general respect/rights, nondiscrimination, and confiden- tiality/privacy all relate to the need to respect the dignity of persons. Simi- larly, caring is crucial because a basic ethical expectation of any discipline in our society is to do no harm. Consequently, it is important for scientists and professionals to show an active concern for human welfare. Special care should be taken when dealing with persons who are most vulnerable. Issues relating to competence and self/knowledge, the need to maximize benefit and minimize harm, and the need to care for the welfare of animals involved in scientific investigations are all underscored by the broad ethi- cal principle of caring. Embedded in the principle of integrity in relationships 330 HADJISTAVROPOULOS is the recognition that relationships with clients/patients come with explicit and implicit mutual expectations that are vital to the advancement of scien- tific knowledge and the maintenance of public confidence in the health-care field. Issues relating to accuracy and honesty, straightforwardness and openness, minimization of biases and avoidance of conflicts of interest, all relate to the need for integrity. The ethical principles relating to responsibil- ity to the society at large are based on the recognition that scientific and pro- fessional disciplines function in the context of human society. A very reasonable expectation of so- ciety is that professions that could not function without societal support will increase knowledge and conduct their affairs in a manner that will pro- mote the welfare of all human beings. Freedom of inquiry and debate are exercised in a manner that is consistent with ethical requirements. Stan- dards relating to respecting and benefiting society and developing knowl- edge are all based on such moral justifications. Application of Ethical Theory In order to demonstrate the manner in which ethical theory can inform ethi- cal actions, one can consider the case of Tracy Latimer. This case has been the focus of much media attention in Canada over the last several years (McGrath, 1998). Tracy was a 12-year-old girl who suffered from severe cere- bral palsy and who had very limited ability to communicate as a result of cognitive impairment.

The reverse side of media influence has been recently illus- trated in an Australian study (Buchbinder buy discount tadacip 20 mg on line, Jolley buy tadacip 20mg visa, & Wyatt cheap 20 mg tadacip, 2001) cheap tadacip 20 mg visa, where a population based multimedia campaign intervention was designed to alter 196 SKEVINGTON AND MASON beliefs about back pain buy generic tadacip 20mg on-line. Studies such as this highlight the power of the media in influencing beliefs about pain and people’s response to it. Level 4: Higher Order Factors Level 4 represents the higher order factors affecting social and psychologi- cal processing that influence the response to pain, such as health culture, history, ideology and politics, quality of life, and economic beliefs about health. For health culture we must ask how particular cultural beliefs foster sickness and wellness in the community. There was a Western cultural tra- dition of prescribing extended bed rest for all low back pain sufferers until the results of Deyo’s seminal study (Deyo, Diehl, & Rosenthal, 1986) showed how this recommendation was contraindicated for those without malig- nancy or herniated disc and indeed, could be iatrogenic. In a wider sense of the word, this issue is also about whether culture en- courages or discourages people from, for example, taking up and maintain- ing exercise that would prevent or retard the onset of a painful condition, or enable people to better cope with it when present. In a recent commu- nity study conducted in a town in northern England noted for its high immi- grant population, a health promotion scheme was set up to enable Bangla- deshi women to cultivate vegetables in publicly owned plots. At the end of the project these formerly housebound women had improved physical, psy- chological, and social health and quality of life: in particular, a boost to their confidence relating to self-efficacy, and less depression. This was as a result of regular contact with other Bangladeshi women, participating in culturally acceptable forms of physical exercise through gardening, and im- proving their family’s diet by cultivating fresh vegetables suited to Asian dishes, to take home (NHS Health Development Agency, UK, 2001). By pro- viding a rationale for exercise, distraction, and social support, such commu- nity pilot projects have the potential to retard the onset of pain, and where pain and disability are present, to maintain mobility, and other aspects of quality of life including good mental health. Health history encompasses the sociocultural history of seeking medical care for pain and other problems, and the reactions of health professionals and significant others on each event, not simply the traditional record of previous illnesses. These higher order factors also relate to the apparent legitimacy of a person’s complaint and help-seeking behavior, that is, whether or not a person’s symptoms are deemed severe enough to justify seeking professional help, particularly when dealing with a phenomenon that other people cannot see. SOCIAL INFLUENCES ON PAIN RESPONSE 197 Health ideology and politics at an individual differences level have rarely been studied in detail in pain research but are necessarily reflected by the predominant premises adopted by the very different health services deliv- ery systems that have been implemented around the world. Those who be- lieve in a socialist medical system, such as the National Health Service in Britain, may wait uncomplainingly on a waiting list for a physiotherapy ap- pointment or scan, despite having trouble sleeping, walking, and working, because they believe that health care should be free at the point of use— that in the current politico-economic context of limited resources and with the assumption of a fair system, they must necessarily wait their turn. In countries where health care is provided through fee for service or health in- surance, those without financial resources or health insurance often suffer without professional care. An individual assessment of health economics, within the ideology of a patient-centered system, might include an evalua- tion of how people in pain believe the resource should be shared out. There is likely to be a continuum from those who hold highly individualistic views, to those who believe that the resources should be used to benefit the great- est number of those in pain. Here, government policy and funding are perti- nent issues and are likely to impact indirectly on how people respond to symptoms, like pain. Policies to withdraw formerly available treatments on the grounds of inconclusive findings of evidence-based medicine may, in the psychological terms of reactance theory (Brehm, 1966; Brehm & Brehm, 1981), make the treatment all the more attractive, and the pain worse as a result of the treatment’s newly inaccessible status. Indeed, recent research has shown a link between patient noncompliance and reactance (Fogarty, 1997; Fogarty & Youngs, 2000). Thus, people are inclined to react adversely when told they must do something. Global inequities in pain relief arising from different governmental poli- cies, have been extensively documented by Stjernsward (1993). This is par- ticularly evident in the field of palliative care concerning the use or with- holding of morphine. Recently McQuay argued that politics, prejudice, and ignorance prevent the most appropriate use of opioid analgesics (McQuay, 1999). Fears of addiction have hindered the effective use of strong pharma- ceuticals for pain relief. This has some resonance with the question of indi- vidual response to pain, not only at a physiological or biochemical level, but also psychologically, as dominant attitudes toward the prescription of strong analgesics can influence the beliefs, attitudes, and behavior of peo- ple with acute and chronic pain. We must also include a consideration of the variable impact of pain on quality of life in health. Without knowing how satisfying or problematic the pain and disability can be, and how much it affects many different aspects of life, we can barely begin to evaluate individual problems. Too often re- searchers and clinicians have erroneously subscribed to a deficit theory, in 198 SKEVINGTON AND MASON the erroneous assumption that the greater the pain intensity, the poorer is the quality of life. There is now substantial empirical data for the quality-of- life literature to show that many of the patients who are in intense pain do not necessarily also have very poor quality of life. This is because the meaning of pain is very different for different people; for some, pain is very threaten- ing and debilitating, whereas for others with the same level of intensity, it plays a less significant role and does not appear to greatly impair their well- being or lifestyle. We need to invest in understanding the variables that me- diate this and other important factors and elucidate the impact that living with pain has on a person’s quality of life.

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Santiago Restrepo C generic tadacip 20 mg mastercard, Gimenez CR generic tadacip 20mg amex, McCarthy K (2003) 13(5):1050–1055 Imaging of osteomyelitis and musculoskeletal soft tissue 28 buy 20mg tadacip amex. Connolly LP buy tadacip 20 mg on line, Connolly SA purchase tadacip 20 mg mastercard, Drubach LA, et al (2002) Acute infections: current concepts. Rheum Dis Clin North Am hematogenous osteomyelitis of children: assessment of 29(1):89–109 Soft Tissue Tumours in Children 67 5 Soft Tissue Tumours in Children Gina Allen CONTENTS 5. References and Further Reading 82 In general any lesion that is solid (echogenic) or partly solid should be investigated further. When there is a clear history of injury and a partly echogenic lesion is found, then it often may be fully assessed 5. However, this must only be performed with Introduction considerable caution as there are occasions where a malignant lesion haemorrhages, hiding the original The finding of a lump by a child or parent is always neoplasm. Although a good history and a definite diagnosis of haematoma from a single US examination can often go a long way in determin- examination. A haematoma, in the early phases, can ing whether a lesion needs further investigation, be solid and echogenic but it will liquefy over the next imaging can often completely reassure the patient few weeks and then resolve. This inevitable alteration and parents that the lesion is benign, permitting in pattern can be used to diagnostic advantage. Whilst soft tissue lowing such a lesion by additional US examination tumours in children are rarely malignant, it is can be invaluable—watching the “swelling” liquefy important to make an early diagnosis when they over a period of days or weeks until its resolution are! An area of injury that becomes “softer” and “smaller” is in keeping with a haematoma. A lump should never be labelled as a haematoma with- out confirmation of resolution by serial US examina- G. Allen, DCH, MRCP, FRCR The Royal Orthopaedic Hospital NHS Trust, Bristol Road tions, thereby avoiding the rare but significant risk South, Northfield, Birmingham, B31 2AP, UK of overlooking a malignant tumour with secondary 68 G. In addition, a lesion that is getting bination of clinical and US features. Any variation larger and “harder” is worrying whatever the imaging should be investigated with MR and biopsy. When resolution is not steady and progressive may help guide the biopsy as heterogeneous tissue it is prudent to perform MR and consider biopsy. On some occasions the US study prompts fur- Features that suggest that the region is more aggres- ther imaging. For example, if the adjacent bone is sive and therefore the best site for biopsy are a high involved or if the “lump” is uniformly solid in nature interstitial water content (where there is reduction and not likely to be a haematoma. A practical and safe approach is to use US to not render diagnostic material. If the lesion is not US can also detect calcification in its very early growing, lies within a normal fatty layer, does not stages often before it is visible on plain films. It invade muscle or other non-fat structure and it is less may therefore be useful in some diagnoses such as than 10 cm in maximum diameter, then a diagnosis phleboliths occurring in a haemangioma and calci- of benign lipoma may be safely made using a com- fication in early myositis ossificans (Fig. It can also be useful if the lesion appears hard to touch and shows some calcification on US. Soft tissue lesions can be present in primary bone tumours such as a Ewing’s sarcoma or infection. Some soft tissue lesions contain calcium deposits which may also be seen on the plain film (for exam- ple, phleboliths and myositis ossificans as discussed above) (Fig. The detection of calcium in soft tissues may also help in short-listing potential diag- noses. Early calcification will be seen on US some time before it casts a radiological shadow. It will answer the following questions: Is there subtle involvement of bone? Signal characteristics often made prosthetic replacement of bone, prior to suggest the composition of the mass, whether it is resection of bone tumours. The main malignancy is made, body CT (chest and sometimes difficulty with MRI in children is that it may be abdomen) is important in the staging of sarcomas. For this reason this The presence or absence of lung metastasis must be examination should be performed in a specialist unit known before embarking on therapy, and therefore where the radiographers are experienced in examin- a CT of the chest is indicated after histological con- ing children and where monitoring with paediatric firmation of this diagnosis. Contraindications Rarely CT of the primary lesion may be the only to MR are less likely in children, but some cardiac option, for example when MRI is contraindicated.

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Athletes should be well Notable exceptions are the persistence of a linear informed and educated prior to the use isotretinoin for black band or streak running the entire length of the severe pustular acne because of the side effects of nail representing a melanocytic nevus or the more muscle soreness purchase tadacip 20 mg online, joint pain tadacip 20 mg on-line, and lethargy (Basler trusted 20mg tadacip, serious involvement of the proximal nail fold in 1989) purchase tadacip 20mg without a prescription. ATHLETIC NODULES BLISTERS Fibrotic connective tissue (collagenomas) because of Vesicles or bulla filled with either serosanguinous repetitive pressure discount tadacip 20 mg overnight delivery, friction, or trauma over bony fluid or blood. CHAPTER 26 DERMATOLOGY 151 Bullous blisters should be drained at the edge with a INGROWN TOENAIL small needle leaving the roof of the blister as a pro- tective layer. CHOLINERGIC URTICARIA Cholinergic urticaria is an acetylcholine-mediated, ENVIRONMENTAL INJURY pruritic dermatosis that occurs commonly on the chest and back during exercise or emotional stress (Houston HEAT and Knox, 1997). COLD MILIARIA CHILBLAIN Miliaria rubra, or prickly heat, occurs in hot, humid Chilblain or pernio is the mildest form of cold injury summer environments. SOLAR URTICARIA Topical corticosteroids or a short burst of oral corti- Solar urticaria is an uncommon cause of urticaria in costeroids may be utilized to minimize the painful, athletes (Kantor and Bergfeld, 1988). FURUNCULOSIS Frostnip can be reversed with immediate self-rewarm- Erythematous, nodular abscesses found in the hairy ing of the exposed area. HERPES GLADIATORUM The sharply, demarcated reddish-brown plaques are Herpes gladiatorum or rugbeiorum refers to a herpes similar in appearance to tinea cruris (Bergfeld, 1984). MOLLUSCUM CONTAGIOSUM The majority of cases respond promptly to topical Characterized by small umbilicated, flesh-colored, antifungal creams, such as miconazole, clotrimazole, and dome-shaped papules. CHAPTER 26 DERMATOLOGY 155 TINEA CORPORIS In extensive disease, oral ketoconazole 200 mg daily Annular lesion having a sharply demarcated, red- for 5 days or 400 mg once a month has been shown dened border with central clearing. ONYCHOMYCOSIS Recent studies reveal oral fluconazole, 200 mg, taken Onychomycosis is a common toenail fungal infection once weekly for 4 weeks had negative cultures after known as tinea unguium and can be attributed to either 7 days in 60% of the wrestlers (Adams, 2002b). MISCELLANEOUS Oral antifungal agents may be required in recalcitrant cases, if the hair roots are involved. CONTACT DERMATITIS Tinea cruris must also be differentiated from candidia intertrigo (scrotal involvement and satellite lesions), Primary irritant dermatitis is a nonallergic reaction that erythrasma (brown and scaly, fluoresces coral red), leads to symptoms within minutes of the exposure psoriasis (silvery scale, pitted nails, and scalp (Bergfeld, 1984). The dermatitis is localized to the con- lesions), folliculitis (punctate pustules), or a chronic tact site and exhibits erythema and a burning sensation. The dermatitis exhibits dermatosis associated with the overgrowth of the patches of erythema, edema, vesicle formation, and active fungal form of Pityrosporum orbiculare known extreme pruritus. Equipment with protective rubber as Malasseziafurfur (Kantor and Bergfeld, 1988). SWIMMER’S ITCH EIA lesions are large and are not produced by hot showers, pyrexia, or anxiety. Sports Med with freshwater and strenuous exercise activate the 32:309, 2002a. J Am Acad Dermatol M eat tenderizer, baking soda, warm saltwater, vinegar 47:286, 2002b. CHAPTER 27 GENITOURINARY 157 Basler RSW: Skin lesions related to sports activity, in Callen JP Houston SD, Knox JM: Skin problems related to sports and (ed. Kantor GR, Bergfeld WF: Common and uncommon dermato- J Am Acad Dermatol 43:299, 2000. Bergfeld WF: Dermatologic problems in athletes, in Lombardo Levine N: Dermatologic aspects of sports medicine. Bergfeld WF, Elston DM: Diagnosis and treatment of dermato- Lewis J et al: Exercise-induced urticaria, angioedema and ana- logic problems in athletes, in Fu FH, Stone DA (eds. Baltimore, MD, Mikhailov P, Berova N, Andreev VC: Physical urticaria and sport. Bergfeld WF, Helm TN: Skin disorders in athletes, in Grana WA, Pharis DB, Teller C, Wolf JE, Jr: Cutaneous manifestations of Kalenak A (eds. J Am Acad Buescher SE: Infections associated with pediatric sport participa- Dermatol 40:S21, 1999. Cohen PR, Eliezri YD, Silvers DN: Athlete’s nodules: Sports- Shelly WB, Raunsley AM: Painful feet due to herniation of fat. Sosin DM et al: An outbreak of furunculosis among high school Conklin RJ: Common cutaneous disorders in athletes. Swinehart JM: Mogul skier’s palm: traumatic hypothenar ecchy- Crowe MA, Sorensen GW: Dermatologic problems in athletes, in mosis. Williams MS, Batts KB: Dermatological disorders, in O’Connor Dover JS: Sports dermatology, in Fitzpatrick TB et al (eds.

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