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By C. Amul. Aspen University.

More than 50% of studies published in a five year period in three UK primary care journals 200 mcg cytotec with mastercard, the British Journal of General Practice (BJGP) buy cytotec 100 mcg low cost, Family Practice and the British Medical Journal (BMJ) were either qualitative studies or surveys of attitude and opinion buy discount cytotec 100 mcg line. The proportion of randomised controlled trials published in US family medicine4 is also relatively small at 3·4% effective 200 mcg cytotec. In a review of nine general surgical journals buy 200mcg cytotec visa, 46% were case series with only 7% randomised controlled trials. This is not always possible but every attempt should be made to use the highest quality evidence available. The strongest evidence supporting clinical intervention is through a meta-analysis or systematic review of randomised controlled trials. But, in many cases, this evidence is not available in a form appropriate to every case and clinicians must decide for themselves based on the best available evidence. Researchers can provide evidence, but the challenge, for most clinicians, is in interpreting this evidence. We should all, therefore, have some knowledge of the skills required to read critically and evaluate the evidence presented in a paper. This chapter looks at the principles of evidence-based medicine and how to appraise the sports medicine literature. Sifting and appraising the literature We cannot read everything so we must triage the literature by its relevance to our clinical practice, educational value, and how effectively it can be applied in practice. The READER acronym8 is a useful model for literature assessment and is one of the few methods that have been formally validated. There is a hierarchy of research methods which determines the quality of a study and the importance that should be attributed to evidence distilled from it. Studies published in sport and exercise medicine are usually found along the spectrum of case reports, case series, cross sectional studies, case control, cohort or randomised controlled trials with little published qualitative work. While the randomised controlled trial is the best method for evaluating treatments and interventions, not all interventions can be assessed using this method. It is the method of choice if appropriate and the strongest evidence comes from systematic reviews or meta-analysis of randomised controlled trials. The Cochrane centres now collate registers of randomised controlled trials,10 some of which are relevant, if not directly taken from sport and exercise medicine. The Quorum guidelines11 can help authors bring together the results in a systematic review of randomised controlled trials. The hierarchy of research methods A single case report should, in general, have little impact on our practice behaviour. It introduces an idea which may merit further study, but alone, it should carry little weight in our management strategy. If we come across a number of individual case reports or a case series this may raise our awareness further but case reports are simply a way of introducing an idea, and are not sufficiently robust evidence to change practice. It describes a particular group of people, athletes or patients at a particular time. If the study has been designed well and the features to be examined are well defined and recorded accurately then it is possible to compare associations across groups. These associations must be interpreted carefully, however, as an association may be spurious and does not necessarily imply causation. This method should allow us to compare two groups, similar in every way but for the feature to be studied. In sport and exercise medicine, this may be an injury or particular physiological feature and identifying two comparable groups, where this is the only differentiating feature, can be difficult. As cases are compared to controls at only one point in time we can only identify the odds that the condition or feature will be present at that time. Clearly the odds of a condition being present are not the same as the risk of a feature developing in a completely unrelated population. In a very large sample the odds approximate the risk. In reading research studies the odds ratio is given in case 5 Evidence-based Sports Medicine control studies analogous to the risk ratio in cohort studies. The advantage of the case control study is that it is relatively cheap to undertake and the results are available relatively quickly. If we wish to identify the risk of an injury or condition, we must look at a sample or population prospectively and identify those in which a particular condition develops. Risk can only, therefore, be identified in a prospective or cohort study.

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The specific alignment goals are to have the shoulders parallel to the pelvis generic cytotec 200mcg with amex, the chest centered over the pelvis generic cytotec 200 mcg without a prescription, and relatively normal sagittal plane alignment with thoracic kyphosis so the cervical spine is straight and the head can be easily held up- Figure 9 order 200mcg cytotec with amex. A definite lumbar lordosis should be present so body weight is moved ment of scoliosis in children with CP is to forward onto the proximal thigh during sitting generic 100 mcg cytotec mastercard, instead of being posterior on maximize their sitting posture buy cytotec 100mcg with amex. When this technical alignment is accom- the goals required are (a) a pelvis that is level with the seat, (b) shoulders that are parallel plished, a positive subjective evaluation of the patients and their caretakers to the pelvis, (c) head balanced over the is additional evidence of the success of the treatment (Case 9. The degree of residual scoliosis on Although families are greatly interested in the nonoperative treatment of sco- the radiograph is less important but usually liosis, there are no nonoperative treatments that have had any documented is less than 30°. Normal kyphosis and lordo- impact on the progression or eventual outcome of the spinal deformity. An examination of her spine demonstrated no the scoliosis made sitting more difficult (Figure C9. Seven years following her hip sur- using Unit rod instrumentation and was well maintained gery, she was again having more problems with seating, 5 years postoperatively (Figure C9. Orthotics Idiopathic adolescent scoliosis has shown beneficial response to bracing, and this concept was translated to children with CP in the early days of de- velopment of spinal orthotics. In the 1970s and early 1980s, there was great enthusiasm with reports of positive effects in children with CP7; however, review of these same patients compared with a control group who were not braced, has shown that there is no change in the rate of progression of the scoliosis or of the final outcome of the magnitude or stiffness of the scolio- sis. A more recent report suggested the possibility of benefit in some children8; however, most individuals in this group still developed scoliosis. Bracing in these children was started as young as age 4 years when there is rarely any real scoliosis present. This study also had no control group and has exactly the same outcome as the earlier report that simply reported the natural history of scoliosis in this group of patients. Unit rod instrumentation and plegia and moderate mental retardation, was seen with fusion were performed without difficulty (Figure C9. His mother cared for him at home and by the seventh day postoperatively, he could sit inde- by herself. During the past year he had grown rapidly and pendent of arm support (Figures C9. His mother used to do standing transfers 1-month postoperative visit, his mother reported that she but he had gotten so heavy that she could no longer do could again do standing transfers with him (Figure C9. Bryan is a self-feeder and in good nutritional Not many children make this kind of dramatic functional condition. On physical examination he could sit inde- gain after spine surgery, but this does demonstrate the pendently if supported by his arms (Figure C9. A possibilities of gain and the rate of typical recovery. After 14 years of brace wear, he still developed C9. Because he was cared for by a profes- and required surgical correction (Figure C9. This corset jacket can be applied over clothes and is used only for sitting to improve children’s sitting posture (Figure 9. This orthosis is never used at night and is simply another alternative to appropriate wheelchair-seating adaptations that allow improved sitting in areas other than the adapted wheelchair. Parents must be instructed that no benefit on the structural scoliosis curve by the use of this orthosis is expected, so the orthosis should be used only at times when it is providing children direct functional benefit. This lack of structural benefit use has to be clarified because parents frequently develop false hopes that the orthotics will pre- vent scoliosis and are then disappointed as the scoliosis continues to increase in spite of orthotic use. Problems with the use of these soft TLSO jackets are that they tend to cause children to become hot in warm weather and may be restrictive enough to impact on their breathing ability. Although one report stressed that the benefit of sitting upright was equal to the restrictive effect of the orthotic, in the balance, children did as well with the brace as without the brace. To assist with prop sitting, a soft TLSO may be used. This assists the prop sit- ting but has no impact on the development or progression of the scoliosis. The most common restrictive problems with the or- thosis occur with feeding, especially in children who are tube-fed and have gastroesophageal reflux.

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Only one included a double-blind evaluation of symptoms (39) cheap 100 mcg cytotec with amex. Although there are no direct Copyright 2003 by Marcel Dekker cheap cytotec 100mcg online, Inc generic 100mcg cytotec. This makes the consequences of a misplaced target reversible with DBS generic 200 mcg cytotec, but irreversible with lesion surgery buy 200mcg cytotec amex. This is most important when considering bilateral procedures, since the risks of dysphasia, dysarthria, dysphagia, and cognitive deficits are increased in bilateral procedures (32–35). Although there are no blinded, evidence-based trial data to indicate which type of surgery to offer, the following guidelines can be considered: 1. If a patient requires a bilateral procedure from the outset, then bilateral DBS is usually preferred over bilateral lesion surgery. This is the case for most patients with advanced PD. If a patient has already had a unilateral procedure (whether a lesion or DBS) and requires a second procedure in the other hemisphere, then DBS should be considered in preference to a lesion since any new side effects from the second procedure are more likely to be reversible. If a patient is considered for a unilateral procedure from the outset, then lesion surgery and DBS should be considered according to the preference of the patient and the surgical center. The longest reported results are 10 years for pallidotomy (40) and 13 years for thalamotomy (18). Despite the untested longer-term safety of either lesion surgery or DBS, there are some general advantages of lesions compared with DBS. First, when health resources of either an individual or a health care provider are limited, it is usual to adopt the more economical option. Lesion surgery avoids the cost of the hardware, the potential cost of repeatedly replacing the implantable pulse generators due to battery failure, and the manpower expenses for programming the stimulators. Second, for patients who live in areas that have no local expertise in maintenance of deep brain stimulators, the placement of a lesion may avoid frequent journeys to a neurosurgical center for stimulator programming. Program- ming is required periodically throughout the time the stimulators are in place. Third, it is possible that with time we shall discover more unique but disastrous complications of stimulators interacting with other electrical systems, such as diathermy for dental treatment (41). Finally, DBS electrodes can fracture, become infected, cause skin erosion, or the battery lifetime may become impractically short. In these instances, a lesion may be the only alternative for patients for whom DBS is no longer suitable for technical reasons. PRACTICAL ISSUES IN THE CHOICE OF A TARGET The three main basal ganglia targets are the pallidum, thalamus, and subthalamic nucleus, and each has been lesioned unilaterally and bilaterally. In considering the results from different reports, it should be emphasized that the methods of clinical assessment, site of target, method of target localization, and method of target confirmation have varied widely among centers. These factors probably account for the differences in clinical outcome across centers. The most comprehensive assessment would have to include: 1. Pre- and postoperative blinded evaluation of objective rating scales, such as the Unified Parkinson’s Disease Rating Scale (UPDRS) Hoehn and Yahr, timed motor tests (28,29), dyskinesia rating scales (43), and cognitive rating scales. Identification of the anatomical target by computed tomography (CT), magnetic resonance imaging (MRI), or CT-MRI fusion. Identification of the physiological target by microrecordings and macrostimulation. Verification of lesion size and location postoperatively by volumetric MRI. It is no wonder, therefore, that reports originating from different centers are rarely directly comparable. The method of target localization can be primarily based on anatomical landmarks, such as stereotaxic CT or MRI coordinates or combined CT-MRI fusion. Most groups will also use macrostimulation at the target site prior to lesioning to check for adverse effects, which most commonly manifest as contraction of the face, arm, or foot, sensory changes, ocular deviations, phosphenes, or speech arrest. Some centers also rely on intraoperative microelectrode recordings from the target site.

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The probe uses sound waves used to cut a flap in the outer layer of the cornea purchase 200mcg cytotec with amex. A com- to emulsify the central core of the lens discount cytotec 200mcg without prescription, which is then suc- puter-controlled laser sculpts the middle layer of the cornea tioned out generic cytotec 200mcg with amex. Then best 100 mcg cytotec, an artificial lens is permanently implanted and then the flap is replaced buy cytotec 200 mcg line. The procedure is typically painless al- minutes and patients recover their vision quickly and usu- though the patient may feel some discomfort for 1 to 2 days ally with little postoperative pain. Structures in the outer, middle, and inner divisions are shown. THE SENSORY SYSTEM ✦ 233 The pinna directs sound waves into the ear, but it is prob- peze). The base of the stapes is in contact with the inner ably of little importance in humans. The skin lining this tube is thin and, in the they do? The wax, or The Eustachian Tube The eustachian (u-STA-shun) cerumen (seh-RU-men), may become dried and impacted tube (auditory tube) connects the middle ear cavity with in the canal and must then be removed. The same kinds the throat, or pharynx (FAR-inks) (see Fig. This of disorders that involve the skin elsewhere—atopic der- tube opens to allow pressure to equalize on the two sides matitis, boils, and other infections—may also affect the of the tympanic membrane. A valve that closes the tube can skin of the external auditory canal. It is a bound- experiencing pain from pressure changes in an airplane. At the posterior of the middle ear cavity is an opening into The Middle Ear and Ossicles the mastoid air cells, which are spaces inside the mastoid process of the temporal bone (see Fig. The middle ear cavity is a small, flattened space that con- tains three small bones, or ossicles (OS-ih-klz) (see Fig. The three ossicles are joined in such a way that they amplify the sound waves received by the tympanic The most complicated and important part of the ear is the membrane as they transmit the sounds to the inner ear. The first bone is shaped like a hammer and is called the It consists of three separate areas containing sensory re- malleus (MAL-e-us) (Fig. The skeleton of the inner ear is called the bony the malleus is attached to the tympanic membrane, labyrinth (Fig. It has three divisions: whereas the headlike part is connected to the second bone, the incus (ING-kus). The incus is shaped like an ◗ The vestibule consists of two bony chambers that con- anvil, an iron block used in shaping metal, as is used by a tain some of the receptors for equilibrium. The innermost ossicle is shaped somewhat ◗ The semicircular canals are three projecting bony tubes like the stirrup of a saddle and is called the stapes (STA- located toward the posterior. Areas at the bases of the semicircular canals also contain receptors for equilibrium. Incus Malleus All three divisions of the bony labyrinth contain a fluid called perilymph (PER-e-limf). Within the bony labyrinth is an exact replica of this bony shell made of membrane, much like an inner tube within a tire. The tubes and chambers of this membranous labyrinth are filled with a fluid called endolymph (EN-do-limf) (see Fig. The endolymph is within the membranous labyrinth, and the perilymph surrounds it. These fluids are important to the sensory functions of the inner ear. Hearing The organ of hearing, called the organ of Corti (KOR-te), consists of ciliated receptor cells located inside the membranous cochlea, or cochlear duct (Fig. Sound waves enter the external auditory canal and cause Stapes vibrations in the tympanic membrane. The ossicles amplify these vibrations and finally transmit them from the stapes Figure 11-13 The ossicles of the middle ear. The handle of to a membrane covering the oval window of the inner ear. The base of the stapes is in contact chambers, they set up vibrations in the cochlear duct. Philadelphia: Lip- a result, the tiny, hairlike cilia on the receptor cells begin pincott Williams & Wilkins, 2003.

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