By Y. Sebastian. Duke University. 2018.

However discount 5 mg proscar with amex, although children of the same age can be at different developmental stages proven 5 mg proscar, the order in which growth and development occurs is generally consistent for all 2 children discount proscar 5mg overnight delivery. For example proscar 5 mg otc, ossification of the carpus occurs in the same order for all children buy 5mg proscar with visa, but the exact age at which the carpal bones ossify can vary markedly. As a result of predictable developmental staging, many texts, including this one, have provided general growth and development charts that are loosely linked to chronological age. These charts are not definitive and radiographers should not rely upon them solely but should combine them with a general understanding of the child development process. Appreciating the social, physical and cognitive developments that occur during these phases of childhood will assist the radiographer in selecting a suitable approach to the examination and will ensure appropriate and effective patient communication and co-operation. Physical growth The peculiarity of growth is what physically differentiates a child from an adult. Infants grow rapidly in the first year of life, increasing their body length by approximately 50%. Between 1 and 2 years of age, a child’s height increases by approximately 12cm and thereafter, until puberty, children increase in height by approximately 6cm per annum. The onset of puberty is associated with a sudden and marked increase in growth (the adolescence spurt) and this phase lasts for approximately 2 to 3 years in both boys and girls. Each organ or system grows at a different rate and therefore the relationship between one part of a growing body and another changes over time3. It is important to note that at birth the head and upper body are larger and functionally more advanced than the lower body. As the child grows, a leaner shape with longer legs is gradually adopted and the relative size of the upper body and head decreases. The rate at which growth occurs varies between children and is also inconsis- tent within an individual child. Growth is episodic rather than constant and Understanding childhood 3 Age 5 Years Physical Growth spurt development Hops, skips, rides bike Start of puberty – girls Growth spurt Basic writing skills Improving pencil Start of puberty – boys manipulation Cognitive Understands Ability to reason logically development conservation of number Increasing ability to reason logically Increasing capacity to remember Social/emotional development Prefers friendships of own gender Adult identity develops Understands Self-esteem decreases concept of trust Peer approval important Increasing value of self-worth Fig. The natural cyclic nature of growth can be adversely affected by serious childhood illness, resulting in decreased growth, and in some children noticeable growth retardation, but upon recovery these children will usually experience a period of accelerated growth until their ‘normal’ height has been achieved. The causes and reasons for episodic rather than constant growth are not yet understood and research in this area continues. However, it appears that each child carries an internal ‘blue print’ that deter- mines their correct growth/height at a particular age and this is likely to be linked to hereditary and environmental factors. Psychological and cognitive development A variety of child development theories have been proposed but, since the 1960s, education theory of child development in the UK has been dominated by Piaget’s cognitive development theory. Piaget believed that the development of cognitive ability (acquisition of knowledge including perception, intuition and reasoning) occurred in sequential stages and he linked these to the chronological age of a child rather than to the intellectual or emotional maturity of the child as favoured by modern theorists. Cognitive development, like physical growth, is individual to the child and their personal experiences. However, a child’s level of cognition directly influ- ences their understanding of, and reaction to, illness4 and there is considerable evidence that a child’s interpretation of health and illness progresses systemati- 5 cally. However, because not all children have the same experiences, some chil- dren will understand more than others at each age. As a result, age is not a good, nor an accurate, indicator of understanding. Birth to 3 years Avery young child has little direct understanding of illness but during this period strong attachments to family members are made and children experience stranger and separation anxiety when in new and unfamiliar situations. To main- tain the security and comfort of the child it is important to include the guardians in the care of their child. Explanation of the procedure should be made in a friendly manner and facial expressions should be welcoming. The attention span and memory of a toddler is short and therefore distraction techniques (e. Explanation of a procedure should be made using lan- guage that the child will understand and the use of pictures, books and toys to Understanding childhood 5 aid explanation5 and a demonstration of equipment to be used (if possible) will help allay fears and gain the child’s co-operation6. Children in this age group will still require the support of a guardian in strange situations and this involve- ment should be encouraged. Care needs to be taken not to under- mine the child and to provide appropriate information that will allow compre- hension and understanding of the medical procedure. For these children, fear of the unknown is still a real problem but expression of this fear or other emotion may be difficult and so a display of ‘bravado’ may occur to mask inner uncertainties.

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A skeletal survey is recommended in nearly all cases to evaluate a more systemic distribution generic proscar 5 mg without a prescription. Progressive involvement of the skull to an advanced degree gives the 145 Malignant soft tissue and bone lesions appearance known as the “geographic” skull trusted 5mg proscar. Involvement of the vertebra can produce a lesion known as verterbra plana (Figure 6 buy 5 mg proscar with mastercard. In the vertebra order proscar 5mg line, the lesion produces intraosseous collapse purchase 5 mg proscar fast delivery, but does not appear to affect the adjacent disc spaces (“coin-shaped” vertebra) (Figure 6. In the long bones, the lesions involve the diaphysis as well as the metaphysis and produce their damage by expansion and erosion from within. A radiographic skeletal survey is indicated, and generally provides more information than radionuclide imaging, as many of the lesions are “cold” on scanning. Treatment consists of closed or open biopsy, and histologic documentation of the nature of the lesion. Eosinophilic granuloma of bone is a benign lesion that generally will undergo spontaneous healing, whether treated or untreated. Decisions to proceed with wide curettage and grafting, intralesional injection of steroids, or simple biopsy and observation, are arrived at by the location within the bone and the Figure 6. Lateral radiograph of the thoracic spine with a characteristic subsequent potential damage from the lesion “coin-shaped” vertebrae associated with vertebra plana (eosinophilic (fracture potential). Lateral cervical radiograph demonstrating vertebra plana seen in histologic diagnosis, proceed to orthopedic eosinophilic granuloma. Malignant soft tissue and bone lesions The basic characteristic of malignant soft tissue lesions is an enlarging, firm, painful mass. Malignant bone lesions are often painful in contrast to benign processes. Persistent growth and increasing firmness of a soft tissue mass are hallmarks of malignancy. Lesions deep to the fascia and greater than 5 cm deserve particular attention. Night pain, loss of motion, and radiographic image evidence of a soft tissue component to a bone lesion increase the index of suspicion for malignancy. Standard radiographic examination of the affected portion of the body is always indicated. If a diagnosis cannot be established on clinical assessment and standard radiographs, Miscellaneous disorders 146 magnetic resonance imaging is almost always the best means of evaluation. Computed tomography scanning and bone scanning are of little use in soft tissue malignancies. Ultrasonography may be preferable to magnetic resonance imaging in popliteal soft tissue masses for popliteal cysts. A core biopsy or open biopsy is the procedure of choice for nearly all lesions and should, if at all possible, be performed by the treating surgeon. Computed tomography scanning provides an excellent view of bone but is of less value for soft tissues. Computed tomography scanning is particularly valuable in evaluating benign bone lesions that may be at risk for fracturing. Magnetic resonance imaging is particularly helpful for the extent of soft tissue involvement and bone marrow involvement. Core biopsy and particularly open biopsy are essential in suspected malignancy to provide adequate tissue for examination. Rhabdomyosarcoma Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood. Tumor staging includes regional lymph node biopsy, chest/ abdominal/ pelvic computed tomography scanning and a bone marrow aspiration. Local therapy consists of complete surgical excision with adjunctive radiation therapy added if there is incomplete excision of the lesion. Rhabdomyosarcomas are 147 Ewing’s sarcoma one of the only soft tissue sarcomas routinely treated with chemotherapy.

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AMA Guides (AMA cheap proscar 5mg with amex, 2000) noted order proscar 5 mg without prescription, “a fundamental divide between a person who suffers from pain and an observer who attempts to understand that suffering cheap 5 mg proscar fast delivery. Observers tend to view pain complaints with suspicion and disbe- lief discount 5 mg proscar mastercard, akin to complaints of dizziness generic proscar 5mg mastercard, fatigue, and malaise” (p. One can find numerous quotes referring to pain insensitivity or pain indifference in infants and young children, children with develop- mental disabilities, children with autism, adults with intellectual disabilities, and elderly persons with dementia. In contrast, fine-grained behavioral studies of the reactions of these people to invasive procedures (deemed painful by people capable of describing the experience) usually yield sub- 318 CRAIG AND HADJISTAVROPOULOS stantial reactions indicative of pain (e. Examples of pain in- sensitivity exist with congenital insensitivity to pain, or among young adults suffering significant neurological impairment, but these appear to be excep- tions (Oberlander, Gilbert, Chambers, O’Donnell, & Craig, 1999). Although there appears to be a rough capability to observe and judge the severity of pain in others, such judgments often represent underesti- mates (Chambers, Reid, Craig, McGrath, & Finley, 1998; Romsing, Moller- Sonngergaard, Hertel, & Rasmussen, 1996; Sutherland et al. The general tendency toward underestimation may be explained through evolutionary theory, which would suggest that it would be to an observer’s advantage to detect pain, but also to make judgments that would result in the least disadvantage to the observer. Williams (2003) ob- served that “the cost to health professionals of overestimating pain (and overprescribing treatment) is considerably higher, and then therefore more warranting conservatism, than for neutral onlookers. The study of judgments of pain in others, whether undertaken by clinicians, family members, or others, clearly requires work as proxy judgments appear to have serious limitations. Efforts have been made to describe criteria clinicians should use to judge the credibility of people who represent them- selves as being in pain. A prominent and influential attempt to do so, rather unsatisfactorily, is reflected in the American Medical Association Guides to the Evaluation of Permanent Impairment (AMA, 2000). This document pro- vides several reasons why reports may lack credibility: “Some people ap- pear unable to provide information that is sufficiently detailed for an exam- iner to assess pain-related impairment. The reasons for this are multiple, including psychosis, severe depression, memory deficits secondary to brain injury, and a lack of cooperation. Other individuals provide detailed information, but the validity of the information is questionable” (p. This list reasonably extends credibility issues beyond voluntary misrepre- sentation to include questions about competence. Although some limited il- lustrations of this are provided (note a substantially more extended analy- sis of pain measurement in people with limited communication competence in Hadjistavropoulos et al. PSYCHOLOGICAL PERSPECTIVES: CONTROVERSIES 319 One must also be concerned about the limited attention devoted to de- velopment of psychological, social, and other environmental interventions, relative to expenditures on pharmacological and surgical interventions. It seems almost self-evident that the latter approaches should receive the most attention. However, that may reflect our inability to contemplate inter- ventions “outside the box” of thinking created by the biomedical model. Caudill, Schnable, Zuttermeister, Benson, and Friedman (1991) showed that participation in a psychosocial pain management program resulted in re- ductions in physician visits as well as decreases in depression, pain levels, anxiety, and pain-related activity interference. Arnstein, Caudill, Mandle, Norris, and Beasley (1999) demonstrated that beliefs in ability to manage and cope with pain (i. Recent analyses of placebo effects indicate that the psychosocial parameters of any intervention are very powerful features, and responsible for some portion of the potency of any analgesic interven- tion (Wall, 1999). Certainly, patient and investigator expectancies are pow- erful determinants of the outcome of clinical trials of analgesics (Turner, Jensen, Warms, & Cardenas, 2002). Recent studies including controls for placebo effects have demonstrated that even sham arthroscopic surgery can substantially alleviate knee pain (Mosely et al. Ordinarily, place- bos constitute the controls for active interventions, with investigators not interested in evaluating the magnitude of impact of the placebo itself and going to extraordinary lengths to rule this impact out. The reasons behind placebo effectiveness are not fully understood, however, and merit further investigation. PUBLIC HEALTH AND POLICY ISSUES There is growing evidence that chronic and acute pain are attracting the concerted attention of the public and public policy makers. Okifuji, Turk, and Kalau- okalani (1999) estimated that over 90 million Americans suffer from some form of persistent or recurrent pain. Health care expenditures and indirect costs associated with disability compensations and loss of productivity re- sulting from absenteeism represent enormous sums of money. Over $125 billion is estimated to be expended annually on health care to treat chronic pain sufferers! Concern for inadequacies in our understanding of pain and pain control led the U. Congress to designate the first decade of the 21st century “The Decade of Pain Control and Research. This lack of attention has long 320 CRAIG AND HADJISTAVROPOULOS represented a problem; traditionally the health care community has em- phasized medical aspects of patient care rather than psychological and so- cial factors (Chambliss, 2000).

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Clark/Treisman 24 Portenoy RK generic proscar 5mg fast delivery, Foley KM: Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases purchase proscar 5 mg. Price DD: Psychological and neural mechanisms of the affective dimension of pain buy proscar 5 mg lowest price. Reich J discount 5 mg proscar free shipping, Tupin J purchase proscar 5mg fast delivery, Abramowitz S: Psychiatric diagnosis in chronic pain patients. Reid MC, Engles-Horton LL, Weber MB, et al: Use of opioid medications for chronic noncancer pain syndromes in primary care. Revenson TA, Felton BT: Disability and coping as predictors of psychological adjustment to rheumatoid arthritis. Riley JL III, Robinson ME: Validity of MMPI-2 profiles in chronic back pain patients: Differences in path models of coping and somatization. Risdon A, Eccleston C, Crombez G, et al: How can we learn to live with pain? A Q-methodological analy- sis of the diverse understandings of acceptance of chronic pain. Robinson RC, Gatchel RJ, Polatin P, et al: Screening for problematic prescription opioid use. Romano JM, Syrjala KL, Levy RL, et al: Overt pain behaviors: Relationship to patient functioning and treatment outcome. Rudy TE, Kerns RD, Turk DC: Chronic pain and depression: Toward a cognitive-behavioral mediation model. Rudy TE, Lieber SJ, Boston JR, et al: Psychosocial predictors of physical performance in disabled individuals with chronic pain. Savage SR: Addiction in the treatment of pain: Significance, recognition and management. Savage SR, Joranson DE, Covington EC, et al: Definitions related to the medical use of opioids: Evolution towards universal agreement. Schult ML, Soderback I, Jacobs K: Multidimensional aspects of work capability. Severeijns R, Vlaeyen JW, van den Hout MA, et al: Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Sheftell FD, Atlas SJ: Migraine and psychiatric comorbidity: From theory and hypotheses to clinical application. Simon GE, VonKorff M, Piccinelli M, et al: An international study of the relation between somatic symptoms and depression. Smith GR: The epidemiology and treatment of depression when it coexists with somatoform disorders, somatization, or pain. Stenager EN, Stenager E, Jensen K: Attempted suicide, depression and physical diseases: A one-year follow-up study. Stewart WF, Ricci JA, Chee E, et al: Lost productive time and cost due to common pain conditions in the US workforce. Stroud MW, Thorn BE, Jensen MP, et al: The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients. Sullivan M, Katon W: Somatization: The path between distress and somatic symptoms. Sullivan MJ, Thorn B, Haythornthwaite JA, et al: Theoretical perspectives on the relation between catastrophizing and pain. Suter PB: Employment and litigation: Improved by work, assisted by verdict. Tan G, Jensen MP, Robinson-Whelen S, et al: Coping with chronic pain: A comparison of two measures. Perspectives on Pain and Depression 25 Taub A: Opioid analgesics in the treatment of chronic intractable pain on non-neoplastic origin; in Kitahata LM (ed): Narcotic Analgesics in Anesthesiology. Turk DC, Meichenbaum D, Genest M: Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective. Turk DC, Okifuji A: What features affect physicians’ decisions to prescribe opioids for chronic noncancer pain patients? Turner JA: Comparison of group progressive-relaxation training and cognitive-behavioral group therapy for chronic low back pain.

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