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Both management not provide severity not groups improved of lateral therapeutic effect described. Investigator the treatment carried forward felbinac plus Assessment (% of acute in analysis. Strength of Evidence ? No Recommendation, Insufficient Evidence (I) Level of Confidence - Low Rationale for Recommendation There are no quality trials of acupuncture for the treatment of ankle sprain. Pending publication of quality studies, there is no recommendation for or against use of acupuncture for treatment of ankle sprain. Strength of Evidence ? Not Recommended, Evidence (C) ? Acute Not Recommended, Insufficient Evidence (I) ? Subacute, chronic Level of Confidence - Low Rationale for Recommendation There is one moderate-quality placebo controlled trial for hyperbaric oxygen therapy that failed to demonstrate any beneficial treatment effect from 2. Author/Y Sco Sam Comparis Results Conclusion Comments ear re ple on Group Study (0- Size Type 11) Borrome 6. Recommendation: Manipulation or Mobilization for Acute or Subacute Ankle Sprain There is no recommendation for or against the use of manipulation or mobilization for the treatment of acute or subacute ankle sprain. Strength of Evidence ? No Recommendation, Insufficient Evidence (I) Level of Confidence - Moderate 2. Recommendation: Manipulation or Mobilization for Chronic Recurrent Ankle Sprain There is no recommendation for or against the use of manipulation or mobilization for the treatment of chronic recurrent ankle sprain. No sprai joint ankle disability index- however, they may significant n mobilizatio activities of daily have an immediate followup to (Gra ns, one living) control vs. However, there is no correlation of improvement to other outcomes such as lost workdays, return to work, or return to sports or normal walking measures, making this finding of uncertain clinical significance. Another moderate-quality trial comparing a single session of mobilization plus movement with no treatment for subacute ankle sprain demonstrated immediate improvement of talocrural dorsiflexion. A high-quality cross-over trial comparing mobilization plus movement with no treatment with or no weight bearing also demonstrated improved talocrural movement, but conclusions of clinical utility are again limited. There is no recommendation for or against manipulation of the ankle and foot joints for acute, subacute, or chronic ankle sprain as there is an absence of quality evidence. Strength of Evidence ? Recommended, Evidence (C) ? Initial injury Recommended, Insufficient Evidence (I) ? Recurrent injury Level of Confidence - Moderate Rationale for Recommendation There are two controlled moderate-quality trials that compare the incidence of ankle sprain injuries in healthy military populations using an ankle brace compared to no brace for intramural basketball participation(551) (Sitler 94) and paratrooper training. Another moderate-quality trial compared bracing to taping for the prevention of sprain during a high school football season and found no difference between groups. There are two low-quality studies of high school athletes also suggesting preventive value of a lace-up brace. Ankle supports are non-invasive, have low adverse effects, and may be of moderate to high cost, particularly for daily taping or use of multiple braces over a season. For contact talofibular and incidence lower pre- in healthy injuries, those who calcaneofibular with brace participati military wore ankle ligament injuries group. Study on, recruits stabilizers had were significantly completed in clinical, intramural fewer ankle reduced with ankle young military functional basketball injuries compared stabilizer use. The difference existed hic incidence of knee between the ankle evidence injury not stabilizer and of ankle significant control groups in instability between the 2 the frequency of groups.

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Diagnosis requires a should be obtained if the diagnosis remains in ques- high index of suspicion. The (B) oblique and (C) lateral views show a exed posture of the 5th metacarpal, abnormal dorsal prominence of the metacarpal bases and a coronally oriented fracture of the dorsal, distal hamate (C, arrow). A dorsal, coronally oriented capitate fracture resulted from this injury because the capitate has a facet for articulation with the 4th metacarpal. This patient had a complete, preoperative motor palsy of the ulnar-innervated intrinsic hand muscles that resolved over 8 weeks. Excision of the ununited fragment pro- vides reliable symptomatic and functional improve- rapezial fractures comprise approximately 3% of ment. Additional soft-tissue attach- involve the base of the ridge and typically heal with ments include the abductor digiti minimi and the trans- immobilization. Examination should exclude other wrist in- cribed dorsal triquetral fractures to the lunate. Palmar pole frac- projections that bring the pisiform and pisotriquetral tures may result from avulsion by the long and short joint into prole are the carpal tunnel view and the radiolunate ligaments. Examination reveals painful wrist motion and lo- Most pisiform fractures can be treated with splint calized tenderness when the fracture is dorsal. Symptomatic posttraumatic osteoar- tures of the lunate may be the radiographic harbinger thritis or nonunion can be treated with pisiform enu- of a more global carpal injury (eg, perilunate disloca- cleation and reconstruction of the exor carpi ulnaris tion) and demand rigorous evaluation of the wrist. A minimally displaced fracture of the (A) lunate volar pole was treated with cast immobilization. The patient developed signicant displacement of the (B) volar lunate fragment (arrow) and midcarpal collapse with severe lunate exion and palmar subluxation of the capitate. Radiographs frequently fail to visualize or underesti- functional loss of the dorsal component of the scapholu- mate the size or displacement of fracture fragments. Occasionally, dorsal lunate avul- because even seemingly innocuous, isolated fractures sion fractures are limited to the attachment of the may functionally detach critical wrist ligaments and scapholunate interosseous ligament (Fig 8). Neutral- meticulous follow-up care to ensure that wrist mal- ization of axial loads with an external xator may assist in alignment does not develop. Patients should be counseled Palmar pole fractures require reduction and xation that lunate fractures can be complicated by avascular because they produce functional loss of the long and necrosis, nonunion, and carpal malalignment. Failure to recognize and treat this injury can produce chronic palmar subluxation of the capitate and he capitate is central and well protected within the midcarpal arthritis (Fig 7). Capitate fractures pole fractures require xation because they can produce comprise approximately 1% of all carpal fractures. Examination revealed tenderness over the scapholunate ligament and a positive Watsons maneuver during examination under anesthetic. Standard wrist radiographs may not reveal isolated body or dorsal articular margin fractures. Lunate body fracture (arrow) produced by an axial fractures can show fractures that do not manifest on loading injury. Magnetic resonance imaging is use- placement and articular impaction are difcult to discern on ful to predict healing potential of transverse body plain radiographs.

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Reuse of any glassware consumables should be avoided whenever possible, unless it 2. A good light source placed near the water bath can be demonstrated that test results are unaf- to accurately observe clot formation. An increasingly large number of semi-auto- ? safety assessment (mechanical, electrical, mated and fully automated coagulometers are microbiological) now available. In many cases this equipment has ? availability of suitable training the following advantages: 2. Information is required in relation to the perfor- ? Accuracy of end-point reading. All equipment requires maintenance to be kept ? interfering substances in good working order. It is good practice to ensure continuity of supply Selection of coagulometers of a chosen reagent, with attention paid to conti- nuity of batches and long shelf-life. Many coagulation analysers are provided as a achieved by asking the supplier to batch hold for package of instrument and reagent, and both the laboratory, if possible. Other important recommended unless there are supply prob- issues to consider are: lems or because of questionable results. Diferent ? type of tests to be performed and the work- brands may have completely diferent sensitivi- load, as well as workfow, in the laboratory ties and should not be run side by side. Instructions supplied with the reagent should humidity, temperature, etc) be followed. Once a reagent is reconstituted or thawed ? ability to combine with reagents from other for daily use, there is potential for deterioration manufacturers over time depending on the conditions of storage ? user-programmable testing and use. Once an appropriate test and reagents have been yser and any back-up methods decided upon, normal/reference ranges should ? compatibility with blood sample tubes and ideally be defned, and must take account of the plasma storage containers in local use conditions used locally. Laboratories are strongly advised to participate in ability of laboratory testing and reporting. It is the responsibility of everyone involved to dence between a laboratory and its users. Other national and international quality assess- and diagnose hemostatic abnormalities. In order for a laboratory to attain a high level of of precision of a particular technique. For screening tests of hemostasis, normal and and techniques and an appropriate number of abnormal plasma samples should be included adequately trained staf.

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Medical procedures should include a full history, including family history, and a full physical examination carried out in accordance with 6. Controllers are to be examined every four years until the age of 40, then every two years (and after age 50 preferably once per year), and it is important to exclude, so far as possible, any cause for incapacitation during this time. Research generally supports the value of psychological testing as a measure of such aptitude, aiming at predicting adequate performance during the controllers career, although the most appropriate tests are subject to ongoing debate. Research conducted in one Contracting State has shown a higher incidence of stress-related illness such as hypertension and peptic ulceration as compared with a control population. Stress-related factors in air traffic controllers Stressful factors Non-stressful factors Being overloaded Responsibility for safety and lives Boredom High work load Failure to conform by others Shift working 16. A good occupational health programme is clearly of value and, as an example, close attention should be paid to short-term sickness absence for apparently trivial conditions as a good indicator for stress. Experience has shown, however, that some controllers still report a build-up of stress because apparently none of these channels is available to them. If correction is needed to perform one or more of these tasks, one pair of glasses should meet the requirements, so that it is unnecessary to remove or change the glasses when operating. Special correcting spectacles, suitable only for the work place, may be necessary. Varifocal lenses are a good solution for many although they may cause some peripheral distortion and often require several days of familiarization before they can be used on duty. Single-vision near correction (full lenses of one power only, appropriate for reading) may be acceptable for certain air traffic control duties (whereas they are not for pilots). However, it should be realized that single-vision near correction significantly reduces distant visual acuity. In such cases, as mentioned under the section on coronary heart disease, the licence may be endorsed as follows: Subject to a similarly qualified controller being in close proximity while the licence holder is exercising the privileges of the licence. However, fatigue is an important risk to flight safety and one which appears to be of increasing importance. They may also be asked to provide guidance to aircraft operators concerning the avoidance of fatigue. It addresses individual mitigation strategies and does not attempt to cover those aspects of fatigue risk mitigation that are addressed by management, such as limitations of duty periods and provision of adequate rest opportunities. Further information can be obtained from standard textbooks, such as that referenced at the end of this chapter. Amendment 33 to Annex 6 (applicable in 2009) introduced substantial changes to the flight time, flight duty periods, duty periods and rest scheme applied to flight and cabin crew (cabin crew, while not licensed under Annex 1 requirements, are also subject to these provisions). Transient fatigue may be described as fatigue that is dispelled by a single sufficient period of rest or sleep. Cumulative fatigue occurs after incomplete recovery from transient fatigue over a period of time. These regulations shall be based upon scientific principles and knowledge, with the aim of ensuring that flight and cabin crew members are performing at an adequate level of alertness. In addition, some definitions from Annex 6 of terms related to fatigue are important and these, along with comments related to their use in practice, are provided in Appendix 1 to this chapter.