睿学教育Wisdome Education

Philippe R. Housmans, MD, PHD

• Professor, Department of Anesthesiology
• Mayo Clinic
• Rochester, Minnesota

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In children antibiotic resistance animation ks4 arzomicin 500 mg buy cheap, abdominal thrusts are substituted for abdominal thrusts after the second five chest thrusts after the second round of back blows infection knee joint trusted 250 mg arzomicin. Use the upright position Subsequently antibiotic vs anti infective order discount arzomicin online, back blows are combined with chest thrusts or (Heimlich manoeuvre) if the child is abdominal thrusts in alternate cycles until the airway is cleared. Up to five Paediatric advanced life support sharp thrusts should be directed upwards The use of equipment in paediatric resuscitation is fraught with toward the diaphragm ● Abdominal thrusts are not recommended difficulties. Not only must a wide range be available to in infants because they may cause damage correspond with different sized infants and children but the to the abdominal viscera rescuer must also choose and use each piece accurately. Basic life support algorithm Airway and ventilation management Ventilate/oxygenate Airway and ventilation management is particularly important in infants and children during resuscitation because airway and Attach defibrillator/monitor respiratory problems are often the cause of the collapse. The airway must be established and the infant or child should be ventilated with high concentrations of inspired oxygen. Assess rhythm Airway adjuncts ± Check pulse Use an oropharyngeal (Guedel) airway if the child’s airway cannot be maintained adequately by positioning alone during bag-valve-mask ventilation. A correctly sized airway should VF/VT During CPR Non VF/VT extend from the centre of the mouth to the angle of the jaw • Attempt/verify: Asystole; when laid against the child’s face. A laryngeal mask can be used Tracheal intubation Pulseless Intraosseous/vascular access electrical for those experienced in the technique. Defibrillate • Check activity Tracheal intubation is the definitive method of securing the as necessary Electrode/paddle positions and contact • Give Adrenaline airway. The technique facilitates ventilation and oxygenation Adrenaline (epinephrine) every 3 minutes and prevents pulmonary aspiration of gastric contents, but it (epinephrine) • Consider anti-arrhythmics does require training and practice. A child’s larynx is narrower CPR • Consider acidosis 1 minute Consider giving bicarbonate CPR 3 minutes and shorter than that of any adult and the epiglottis is relatively • Correct reversible causes longer and more U-shaped. The larynx is also in a higher, more Hypoxia anterior, and more acutely angled position than in the adult. Hypovolaemia Hyper- or hypokalaemia A straight-bladed laryngoscope and plain plastic uncuffed Hypothermia tracheal tubes are therefore used in infants and young Tension pneumothorax Tamponade children. In children aged over one year the appropriate size of Toxic/therapeutic disturbances tracheal tube can be assessed by the following formula: Thromboemboli Internal diameter (mm) (age in years/4) 4 Infants in the first few weeks of life usually require a tube of Algorithm for paediatric advanced life support size 3-3. Basic life support must not be interrupted for more than 30 seconds during intubation attempts. After this interval the child must be reoxygenated before a further attempt is made. If intubation cannot be achieved rapidly and effectively at this stage it should be delayed until later in the advanced life support protocol. Oxygenation and ventilation adjuncts A flowmeter capable of delivering 15l/min should be attached to the oxygen supply from either a central wall pipeline or an independent oxygen cylinder. Facemasks for mouth-to-mask or bag-valve-mask ventilation should be made of soft clear plastic, have a low dead space, and conform to the child’s face to form a good seal. The circular design of facemask is recommended, especially when used by the inexperienced resuscitator. The facemask should be attached to a self-inflating bag-valve-mask of Guedel oropharyngeal airways either 500ml or 1600ml capacity. The smaller bag size has a pressure-limiting valve attached to limit the maximum airway pressure to 30-35cm H2O and thus prevent pulmonary damage. Occasionally, this pressure-limiting valve may need to be overridden if the child has poorly compliant lungs. An oxygen reservoir system must be attached to the bag-valve-mask system, thereby enabling high inspired oxygen concentrations of over 80% to be delivered. The Ayre’s T-piece with the open-ended bag (Jackson Reece modification) is not recommended because it requires specialist training to be able to operate it safely and effectively. Management protocols for advanced life support Having established an airway and effective ventilation with high inspired oxygen, the next stage of the management depends on the cardiac rhythm. The infant or child must therefore be attached to a cardiac monitor or its electrocardiogram (ECG) monitored through the paddles of a defibrillator. Laerdal face masks 46 Resuscitation of infants and children Non-ventricular fibrillation/non-ventricular tachycardia Two arrest rhythms Asystole is the commonest cardiac arrest rhythm in infancy and childhood.

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Have you ever been stopped in the street and asked about washing powder or which magazines you read? Or have you been invited into a hall to taste cider or smell washing-up liquid? The interviewer asks you a series of questions and ticks boxes with your response antibiotics for cellulitis purchase 500 mg arzomicin visa. Structured interviews are used in quantitative re- search and can be conducted face-to-face or over the tele- phone bacteria 37 degrees celsius arzomicin 100 mg purchase with mastercard, sometimes with the aid of lap-top computers virus website arzomicin 500 mg buy without a prescription. FOCUS GROUPS Focus groups may be called discussion groups or group in- terviews. A number of people are asked to come together in a group to discuss a certain issue. For example, in mar- ket research this could be a discussion centred on new packaging for a breakfast cereal, or in social research this could be to discuss adults’ experiences of school. She makes sure that no one person dominates the discussion whilst trying to ensure that each of the participants makes a contribution. THE FOCUS GROUP METHOD: ADVANTAGES AND DISADVANTAGES ADVANTAGES DISADVANTAGES Can receive a wide range of Some people may be responses during one meeting. Helps people to remember issues Other people may contaminate they might otherwise have an individual’s views. Helps participants to overcome Some researchers may find it inhibitions, especially if they difficult or intimidating to know other people in the group. The group effect is a useful Venues and equipment can be resource in data analysis. Participant interaction is useful Difficult to extract individual to analyse. QUESTIONNAIRES There are three basic types of questionnaire – closed- ended, open-ended or a combination of both. Closed-ended questionnaires Closed-ended questionnaires are probably the type with which you are most familiar. Most people have experience of lengthy consumer surveys which ask about your shop- ping habits and promise entry into a prize draw. This type of questionnaire is used to generate statistics in quantita- tive research. As these questionnaires follow a set format, and as most can be scanned straight into a computer for ease of analysis, greater numbers can be produced. Open-ended questionnaires Open-ended questionnaires are used in qualitative re- search, although some researchers will quantify the an- swers during the analysis stage. The questionnaire does not contain boxes to tick, but instead leaves a blank sec- tion for the respondent to write in an answer. Whereas closed-ended questionnaires might be used to find out how many people use a service, open-ended question- naires might be used to find out what people think about a service. As there are no standard answers to these ques- tions, data analysis is more complex. Also, as it is opi- nions which are sought rather than numbers, fewer questionnaires need to be distributed. Combination of both Many researchers tend to use a combination of both open and closed questions. That way, it is possible to find out how many people use a service and what they think about that service on the same form. Many questionnaires begin with a series of closed questions, with boxes to tick or scales to rank, and then finish with a section of open- questions for more detailed response. This suggests that soon there might be a new category of ques- tionnaire – the interactive questionnaire, which allows re- spondents to work with the researcher in both the development and completion of the questionnaire. PARTICIPANT OBSERVATION There are two main ways in which researchers observe – direct observation and participant observation. Direct ob- servation tends to be used in areas such as health and psy- chology. It involves the observation of a ‘subject’ in a certain situation and often uses technology such as video cameras or one-way mirrors. For example, the interaction of mother, father and child in a specially prepared play room may be watched by psychologists through a one- way mirror in an attempt to understand more about fa- mily relationships. In participant observation, however, the researcher becomes much more involved in the lives of the people being observed.

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In 1924 he introduced into with royal approval bacteria fermentation buy arzomicin 500 mg with amex, redesignated Queen Mary’s England “traction by suspension” for the treat- Hospital for Children in 1914 antimicrobial resistance surveillance generic arzomicin 250 mg buy line. Here he remained ment of tuberculosis of the hip at the suggestion for the rest of his professional career infection game plague inc buy arzomicin 500 mg low price. In 1926 Pugh was president of the orthopedic The original apparatus used at Carshalton con- section of the Royal Society of Medicine. He was sisted of a fracture board and mattress on which an early member of the British Orthopedic the child was placed with the feet towards the Association, and in 1935 he was elected to the head of the bed. Skin extension was applied direct Fellowship of the Royal College of Surgeons of to the affected limb, the extension straps were England. Lateral rotation of the limb was Asylums Board in 1907, consisted in the main prevented by a sandal attached to a horizontal of 24 single-storey ward blocks with over 900 wooden bar, and a further wooden bar was placed beds. The buildings were originally intended for under the mattress at knee level to prevent back- a convalescent fever hospital but had never been ward subluxation of this joint. They were situated in 136 acres of tion by suspension” usually sufficed to correct hip parkland on the Surrey Downs. The child was some of the ward blocks in order to provide an allowed relatively free mobility on the bed but operating theater, gymnasium and appliance was prevented from turning over by a chest band. Ini- courtyards on the south side of each ward block tially, and with success, he used two large mole- in which 300 children might live, day and night, skin plasters, which enveloped the thigh. London area on the authority of the boards of Pugh also modified Robert Jones’ abduction guardians and the London County Council. Under frame to give traction by suspension in patients Pugh’s guidance, special units were set up within with advanced tuberculosis of the hip in whom the hospital to care for children with skeletal the desired result was ankylosis in the best posi- tuberculosis, poliomyelitis, cerebral palsy and tion rather than a mobile joint, as was often rheumatic fever. The undulating countryside obtained by “Pugh’s traction” in early cases. In provided ideal conditions for the open-air treat- the early 1920s, the first tip-up hip carriage was ment of skeletal tuberculosis so popular at that produced and this was essentially the fracture time. In addition, enforced rest, adequate diet and board on wheels, elevated to 30 degrees from the conservative surgery, which included the aspira- horizontal. When there was clinical and radi- “There had never yet been devised a jacket or ological evidence of healing, many children were splint... Pugh argued that hyperextension opened side, thus elevating each kidney in turn to up a gap between the vertebral bodies, which improve urinary drainage. The lesion would high fluid intake, restriction of dietary oxalate and then heal with fibrous tissue, which allowed oral administration of potassium citrate, solved recurrence of the deformity on assumption of the the problem. In 1933 Pugh introduced a second upright posture, despite the support of a jacket or hip carriage in which the spinal frame was brace. He was also against posterior spinal bone mounted on rollers on a backward inclined slope grafting as a method of shortening the duration of to produce traction by suspension. He regarded the procedure as per- spinal carriage, a rotary device was incorporated. The operation was often done while the to lie in the more comfortable horizontal disease was still active in an endeavor to reduce position. Pugh commonest single cause of crippling in children argued that the center of gravity for the body was in the London area,9 and in 1924 the London well in front of the spinal column and that if County Council designated 50 beds at Queen recumbency was discontinued before healing was Mary’s Hospital for the treatment of this condi- well advanced, collapse of the vertebral bodies tion in the second stage, that is, from the loss could occur anteriorly. Furthermore, the graft pre- of muscle tenderness until the disease became vented telescoping of the vertebrae and main- stationary. Pugh did not believe in outpatient tained the space between them with a persistent treatment, as was commonly practiced then, and abscess and further sinus formation. Pugh attempted to neutralize the defor- ered that heat, massage and electrical stimulation mity after arrest of activity by encouraging the were beneficial, although he was fully aware of compensatory curvature in the healthy region of the dangers of fatigue. An outdoor his children, spinal caries developed before the heated swimming pool was constructed for the age of 6 years, when the shape of the spine was use of these patients in 1927. Constructed of suspension” remains of considerable value for gas piping, the frame was shaped individually for the treatment of children with transient synovitis each child to produce the appropriate compensa- of the hip, Legg–Calvé–Perthes’ disease, coxa tory spinal curvatures. The child was secured to vara,11 and fractures of the femoral shaft, and pro- 282 Who’s Who in Orthopedics vides a memento of “Pugh of Carshalton,” who foreign editor of The Journal of Bone and Joint devoted his life to the care of crippled children. The Cathedral of San Pietro e San Paolo, built in part from the References Roman remains, was erected in the fourth century. D’Arcy Power, Le Fanu (1953) legends attribute the founding of the famous Uni- 2. Wastson-Jones (1952) student population has decreased, but the medical school of the university is still outstanding.

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During the in- terview antibiotics dog bite buy 500 mg arzomicin mastercard, Lonnie didn’t want to sit in her wheelchair—no surprise! One of Lonnie’s eyes bore the opalescent blue of blindness behind thick glasses infection lung cheap arzomicin generic, but we main- tained eye contact during the entire interview infection hair follicle generic arzomicin 100 mg overnight delivery, she fixing me somewhat skepti- cally with her remaining eye. Most of her teeth were missing, and her hair had receded like a man’s, the remainder a grizzled gray. She wore round-toed, clay- colored orthopedic shoes, her legs encased in gray support hose. She also worked part-time in various jobs, including as an advocate for minorities with disabilities. Despite that, she was poor, widowed, lived alone in a low-income housing complex, and received Medicaid health in- surance. Carter experienced the most blatant outright hostility reported by any interviewee, attributing this abuse to her disability. Teenage boys in her housing project taunted her, saying she shouldn’t go out. Lonnie dished it right back, for exam- ple, making a “citizen’s arrest” of someone blocking a curb cut with their car and verbally contesting the teenage boys. Although Lonnie spoke at length, at the outset talking for twenty minutes without pause, I also sensed wariness. Fred Daigle Early sixties; white; married to Martha, with several grown children; seventh- grade education; retired from job as painter and handyman; low income; severe chronic lung disease related to asbestos exposure and smoking, heart disease; required supplemental oxygen; walked slowly short distances in home without assistance. DiNatale is in her mid forties, white, and of Italian descent—as she noted repeatedly. We met on a hot, sunny afternoon at her modest one-story clapboard house in a middle-class town outside Boston. A small swimming pool shimmered in a fenced enclosure outside sliding doors along a kitchen wall. Tina was darkly tanned and dressed entirely in black (long- sleeved India cotton top, flowing pants), wearing black thong sandals with a slight heel. Her husband, Joe, a big, muscular man of the strong silent type, seemed anxious to slip out the door—he was working an early evening shift. We talked in an open area with a circular table and rolling chairs adjacent to the kitchen. DiNatale had designed the kitchen in a U-shape so that she wouldn’t have far to walk to perform any task. She keeps a padded bar stool on the inner circumference of the U-shaped counter where she presides over meals; Joe calls her stool “control central. Tina got around her house by grabbing everything in sight and running her hands along the wall at shoulder height (chapter 11). DiNatale has a college degree, she has not worked for almost twenty years, and she and Joe decided not to have children. She was frustrated with her experiences with Mass Rehab, exploring retraining to find a suitable job. She felt that they treated her very poorly: “Just because I had a college degree, I got nothing. DiNatale therefore spends much of her time alone at home, although she still drives short distances, occasionally seeing family and volunteering at her church. She searches the Internet and keeps abreast of current events but some- times feels isolated. For our conversation, she had prepared a written list of talk- ing points about her experiences and opinions on mobility problems. DiNa- tale was searching for a doctor who suited her desires (someone who would listen to her concerns, respect her viewpoint, watch her walk, and not seem rushed) and for the perfect lightweight wheelchair. When I contacted her by e-mail about two years after our interview, she said she was doing about the same. Erna Dodd Mid fifties; black; several grown children, raising two grandchildren; fifth- grade education; retired from housekeeping jobs; low income; emphysema, di- abetes requiring insulin, congestive heart failure, seizures, obesity, and arthri- tis from degenerative joint disease; used walker holding oxygen canister and sometimes used manual wheelchair. Died at home within a year of the inter- view, probably from lung failure. Barney Fink Early sixties; married to Rachel, with several grown children; graduate degree; retired from optometry practice; middle income; Parkinson’s disease; no mobil- ity aids but walks slowly.

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The ligaments and tissue around the shoulder capsule or joint become inflamed and stiff virus barrier arzomicin 100 mg buy amex. Usually this occurs after surgery or a fracture of the arm when the limb is immobilized antibiotic brand names arzomicin 250 mg buy online. Leonard’s history didn’t seem to have any of the things that normally cause frozen shoulder antibiotic bloating buy cheap arzomicin 100 mg on line. But his notebook repeatedly made mention of this problem occurring after he moved from the suburbs to Manhattan. He even joked about possibly being “allergic” to the city as a cause of his problem. Rosenbaum asked him to return to his journal, act like a medical detec- tive, and specifically list what in his life had changed since he moved to the city, using what he now knew about the causes of frozen shoulder—surgery, immobilization, or a physical trauma or injury. Leonard realized that the change from suburb to city was mainly in the form of exercise. Rosenbaum that both shoulders were being affected so Leonard had to be doing something with both arms. He asked Leonard to do an experiment using the treadmill: to run and describe exactly what he did with both arms while he ran. He reminded Leonard not to make any assumptions and to keep an open mind. Leonard did what he was told and immediately realized he was lean- ing both his arms on the support bars of the treadmill while running. By using his shoulders to support his weight, Leonard was probably causing progressive microtrauma to both shoulder joints. As the pain from the trauma intensified, Leonard began guarding against the pain by not using them. First he was immobilizing them as he Are Your Ways of Staying Healthy Making You Sick? Then he was immobilizing them further by refusing to use them because of the pain, giving himself a double whammy. Conclusion Attempting to stay healthy through diet and exercise is certainly recom- mended. However, as with Maria, Jennifer, and Leonard, exercise and diet- ing can be hazardous to your health if not done properly and with supervision. And don’t forget to analyze your own so-called healthy habits when searching for clues to your mystery malady. Ask yourself these questions: • Have you begun any new routine or regimen in an attempt to get or stay healthy? Neck, back, and joint pain affects a whopping 60 to 85 percent of the population at any given time. Musculoskeletal and joint pain often starts without warning and for no obvi- ous or easily explainable reason. In other cases, it becomes recurrent and we don’t know why we are hurting or how to fix it. Most of the time, with this kind of pain, people just assume they have injured themselves, and the injury was the precipitating cause of their pain. In this chapter, we share several interesting cases of seemingly unex- plainable muscle or joint pain. Once these frustrated patients used the Eight Steps, they finally found the correct diagnosis and obtained relief from their pain. Being an active young man and having injured various parts of his body at one time or another, he knew the drill. When he got home, he iced the most painful area of his back, laid down, and later applied moist heat. He felt reasonably certain the pain would diminish before he went back to work on Monday. In fact, the pain remained fairly intense and persisted the entire week. He was x-rayed and when it was determined his pain was probably a soft tissue injury, he was treated with nonsteroidal anti-inflammatory drugs and given a prescription for physical therapy, which he pursued twice a week for several weeks. The drugs and physical therapy helped somewhat, but they didn’t com- pletely resolve his problem. He figured out that if he kept moving around—walking, riding a bike, or doing any other activity (including sex), he had less back pain.

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Various self-learning materials are also available for the students to use in their own time infection you can get when pregnant generic 100 mg arzomicin. Though such a programme is far from perfect bacteria en la sangre discount arzomicin 250 mg otc, it was introduced within a traditional curriculum and with the minimum of resources antibiotics z pack buy arzomicin on line. The main change was a reallocation of staff time away from didactic activities and into more direct observation of student performance. A perusal of the medical educational literature will provide you with other examples of structured clinical teaching. Increasingly you will find descriptions of the use of clinical skills laboratories where medical schools have set up fully staffed and equipped areas devoted to putting groups of students through an intensive training in clinical skills, often using a wide range of simulations. You will also find many examples of training students in interpersonal and communication skills using simulated patients. All have the same general approach: to undertake the training of various clinical skills in a structured and supervised way to ensure that all students achieve a basic level of competence. TECHNIQUES FOR TEACHING PARTICULAR PRACTICAL AND CLINICAL SKILLS Many practical and clinical skills can be taught as separate elements. Because there is a wide range of these elements, and as clinical teaching is generally opportunistic, many medical schools have established programmes to teach basic skills in a piecemeal fashion. This is normally done early in the students’ career, often just prior to their first clinical attachments. This section will introduce you to a variety of ways of teaching basic skills some of which may not be of immediate relevance but some of which ought to be in operation in your medical school because of their proven efficacy. Video recording: any department which has the respon- sibility for teaching aspects of history taking or inter- personal skills should have access to video recording equipment, preferably of the portable kind that can be set up in ward side rooms, outpatients and other teaching situations. You should become familiar with the technical operation of the equipment. The simplest is to record examples of interviewing techniques (good and bad) for demonstration purposes. You may also wish to have an example of a basic general history so the novice student can get an idea of the questions that are routinely asked. Some medical schools have recorded segments of interviews with patients which show various emotional reactions (e. The most powerful way of using the video is to record the student’s interview with a patient remembering that informed consent is essential. This may be initially stressful but both student and patient usually forget they are being recorded after a few minutes. The student, or a small group of students, meet later with the teacher to review the tape. Firstly, the situation must be a supportive one to allow frank and open discussion. Secondly, the teacher must have a clear idea of what the students should be learning. Such things as non-verbal cues, aspects of doctor-patient relationships, avoidance of jargon, adequacy of questions, direction of the enquiry, directive versus non-directive questioning, hypothesis generation and many other issues can be 81 identified and discussed, both with the interviewing student and with the student’s peers. There are clearly several advantages of this approach over direct observation: the teacher is not committed to be present at the actual interview; the teaching can be scheduled at a convenient time; a recorded interview can be interrupted as often as necessary; and most importantly the students can review their own performance. The latter by itself often produces a striking impact and a rapid improvement in competence. Simulation: the use of simulated (or standardised) patients is another well-proven and powerful method for teaching interview skills. However, if does require some expertise to train the simulated patients and if you wish to pursue this technique we strongly recommend that you read the book by Barrows. The simulated patient offers certain distinct advantages over the real patient particularly for the novice student. The analogy has been drawn with the value of flight deck simulators in pilot training.

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Knee Joint and Diseases of the Knee Joint had He was survived by Jenny antibiotic resistance warning discount arzomicin 500 mg buy on line, two daughters from his preceded him bacteria on the tongue arzomicin 500 mg sale. The first went into five editions and first marriage and Jenny’s three children antibiotics for sinus infection didn't work order arzomicin online. These pub- lications were the result of personal observation, data collection, careful pathological analysis and considered judgment. The operations that he described were effective and saved many knees from considerable malfunction. Although some of these procedures have been superseded by new technology, the basic principles of comprehensive assessment, accurate diagnosis, and progressive rehabilitation still hold. Smillie’s academic and professional career was finally capped by his presidency of the International Society of the Knee from 1981 to 1983. He had many interests outside medicine: he raced exotic cars at Brooklands in the 1930s, and his serious interests included philately and pho- tography. His pervasive interests were farming, fishing and stalking—he published A Guide to the Stalking of Red Deer in Scotland in 1983. Ian Smillie was a complex character; some- times defensive, always enthusiastic, lacing his discussion and instruction with humor. He could Robert William SMITH be cutting in debate, but equally generous in praise when this was deserved. On one occasion, 1807–1873 an arch-rival attacked his techniques and the knives that he had designed, saying “The only use Robert William Smith spent his entire life in for which I can recommend Mr. He waited for it is in surgical pathology that he made his great- what seemed an age, then continued—“The best est contributions. X can make of these knives surgical literature by its association with a frac- is to sharpen pencils”. Treatise on the Pathology, Diagnosis and Treat- His contribution to knee surgery was immense ment of Neuroma, containing an extensive review and surgeons everywhere will miss him, as will of the literature as well as his own observations. In Boston, in addition to and on stone” by the Irish illustrator Connelly, are being instructor in orthopedic surgery at Harvard for the most part life-size. The monograph itself Medical School (1930–1935) and clinical pro- is unusual, being an elephant folio measuring 48 fessor of orthopedic surgery (1935–1946), he ¥ 70cm, and is said to be the largest book ever became chief of the orthopedic service at the published in Ireland up to that time. This Scandinavian–American mixture had the strongest anglophile leanings, and these were further developed by his contact with British orthopedic surgeons, in particular Sir Robert Jones in the latter half of the First World War, and subsequently. From very early days in his medical career, Smith-Petersen was a pioneer. In the course of his Moynihan Lecture in 1947, he himself told the story of the original planning and execution of the anterior approach to the hip joint in 1917, stimu- lated in the first place by Dr. Subsequently, this approach was developed into the acetabuloplasty operation, which he described in 1936 for the relief of pain and restoration of function in cases of malum coxae senilis, old slipped upper femoral epiphysis, intrapelvic protrusion of the acetabu- lum and coxa plana. SMITH-PETERSEN ment in the form of Vitallium mold arthroplasty, 1886–1953 with preliminary trials of several materials, including glass (1923), viscoloid (1925), Pyrex Dr. Smith- virtue of his skill and thought, with reference to Petersen put into his work on arthroplasty of the hip joint surgery in particular, but throughout his hip provoked worldwide interest and progress, professional career his strong personality, mixed and it is to be noted that a long period of research with a great sense of humility and kindness, preceded his final operative technique. Not only was he the “surgical joint dates back to 1930-1931, when he intro- master,” but the friend and confidant of all who duced the use of the three-flanged nail for inter- had the privilege to come into contact with him. At that Although he was somewhat shy and sensitive as time, he wrote: “A great responsibility rests on the an individual, his powers of concentration and surgeon who introduces a new method of treat- real deep thinking made him a great leader and ment. The desire to have a new idea published is teacher in the art and science of orthopedic so great that the originator is often led astray, and surgery. His great aim, both in theory (Harvard) in 1914, and was awarded an Honorary and practice, was to be constructive, and thus we 310 Who’s Who in Orthopedics find him developing many procedures for the English-speaking orthopedic surgeons in London relief of pain and restoration of function in the and the provinces. Fortunately, he had a chance deformed joints of the unfortunate sufferers from of seeing most of his friends and was able to visit chronic arthritis. In 1946, he worked out on paper to the last detail, before was honored with the award of Commander of being put into effect most successfully and the Royal Norwegian Order of Saint Olaf, and dramatically. In honorary member of the Norwegian Surgical this respect he was much influenced by his early Association. Smith-Petersen undoubtedly was seen at his American Orthopedic Association, and held the best when dealing with patients, either on a ward office of president of the American Academy of round or in his office.

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Pacing should be reserved for relation to resuscitation antibiotic for bladder infection discount arzomicin 500 mg line, which need to be addressed virus buster serge buy arzomicin 250 mg overnight delivery. However antibiotics for uti aren't working 500 mg arzomicin, the question arises as to the Such intervention should be reserved for patients with a wisdom and practicality of death being determined in some potentially good prognosis—for example cases of hypothermia, drug overdose, and those with conditions cases by non-medical healthcare professionals, such as nurses amenable to immediate cardiac, thoracic, or abdominal and ambulance personnel. Formal certification must, by law, be undertaken by a registered medical practitioner, and this requirement will not change. Extract of Joint Royal Colleges Ambulance Liaison Nevertheless, it is possible to identify patients in whom survival Committee Guidelines is very unlikely and when resuscitation would be both futile and Group A—Conditions unequivocally associated with death distressing for relatives, friends, and healthcare personnel, and ● Decapitation situations in which time and resources would be wasted in ● Massive cranial and cerebral destruction undertaking such measures. In such cases it has been proposed ● Hemicorporectomy (or similar massive injury) ● Decomposition that the recognition of death may be undertaken by someone ● Incineration other than a registered medical practitioner, such as a trained ● Rigor mortis ambulance paramedic or technician. In introducing such a ● Fetal maceration proposal, it is essential to ensure that death is not erroneously In these groups, death can be recognised by the clinical diagnosed and a potential survivor is denied resuscitation. In addition, (CPR), for more than 20 minutes in a normothermic patient a further group of patients with terminal illness should not be ● Patients who have received no resuscitation for at least 15 resuscitated when the wishes of the patient and doctor have minutes after collapse and who have no pulse or respiratory effort on arrival of the ambulance personnel been made clear. Timings must be accurate No instances have been recorded of patients surviving with In all these cases, the ECG record must be free from artefact the conditions listed in group A, nor of adults who have been and show asystole. There must be no positive history of sedative, submersed for over three hours. Authorities are agreed that it is hypnotic, anxiolytic, opiate, or anaesthetic drugs in the totally inappropriate to commence resuscitation in these preceding 24 hours circumstances. The futility of CPR in patients with mortal Group C—Terminal illness trauma has been highlighted in several publications. Cases of terminal illness when the doctor has given clear The concept of a “Do Not Resuscitate” policy has received instructions that the patient is not for resuscitation international support for patients with terminal illness whose condition has been recently reviewed by the family doctor, in consultation with the relatives and patient where appropriate. Issues in training A study of 1461 patients found that when persistent ventricular fibrillation was excluded, all survivors had a return of Use of the recently dead for practical skills training spontaneous circulation within 20 minutes. No patient survived Opportunities for hands-on training in the practical skills required for resuscitation are limited. In another group of intubation cannot be taught to everyone attending a cardiac 1068 patients who experienced out-of-hospital cardiac arrest, arrest. Although the laryngeal mask may offer an alternative only three survived among those who were transported to option for airway management in the short term, the hospital with ongoing CPR. Those three survivors were introduction of that device on a widespread scale into discharged from hospital with moderate to severe cerebral anaesthetic practice has, in itself, reduced the opportunities for disability. These findings support the proposal that death may training in the anaesthetic room. Manikin training offers an alternative, but most would agree that training on patients is be recognised in normothermic patients who have had a period required to amplify manikin experience. Informed collapse to the arrival of ambulance personnel exceeds consent is difficult to obtain at the sensitive and emotional time 15 minutes, provided that no attempt at CPR has been made in of bereavement, and approaches to relatives may be construed as coercion. Proceeding without consent may be considered as that time interval and the ECG has shown an unshockable assault. This recommendation is supported by a review of 414 The dilemma does not stop with tracheal intubation, and other patients who had not received any CPR in the 15 or more techniques, such as fibre optic intubation, central venous access, minutes to ambulance arrival. No patient survived who had a surgical cut-down venous access, chest drain insertion, and non-shockable rhythm when the first ECG was recorded. This resulted in an algorithm for ambulance personnel 105 ABC of Resuscitation encountering death in these conditions, which has been The involvement of relatives and close friends accepted by the Professional Advisory Group of the Scottish Ambulance Service and the Central Legal Office to the Bystanders should be encouraged to undertake immediate basic life support in the event of cardiorespiratory arrest. Traditionally, The validity of the proposed guidelines depends on the relatives have been escorted away from the victim when the accurate diagnosis being cardiac arrest within the first 15 or so healthcare professionals arrive. The Resuscitation unsupported arrest could be less—perhaps much less—than Council (UK) has confirmed the need to identify and respect 15 minutes. In these circumstances, resuscitation could possibly relatives’ wishes to remain with the victim. Clearly, care and consideration of the relative in these stressful situations become still be successful. When the 15 minute asystole guideline has of increasing concern as the invasive nature of the resuscitation been used in the United States, however, this concern has attempt escalates from basic life support, to defibrillation and proved to be unfounded. These must be disseminated throughout the service and to all other concerned groups. Legal aspects Doctors, nurses, and paramedical staff functioning in their official capacity have an obligation to perform CPR when medically indicated and in the absence of a “Do Not Further reading Resuscitate” decision.

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They may obscure normal sleep architecture and antimicrobial growth promoters 100 mg arzomicin with amex, while not the pattern of electrographic status epilepticus of sleep (ESES) treatment for uti naturally arzomicin 250 mg buy without a prescription, may occupy up to 50% of the recording topical antibiotics for acne uk generic 250 mg arzomicin with amex. Generalized spikes, and in some patients multifocal spikes, can be seen throughout the recording. Neuropsychologic Disturbances Mental retardation is almost universal in LGS, with fewer than 10% of patients pre- serving near-normal intellectual functioning. Children may appear normal or near normal at onset with an abrupt deterioration following the onset of uncontrolled sei- zures, or may have a preceding encephalopathy, including infantile spasms. Overall, cognition progressively deteriorates, compounded by repeated trauma from falls and the effects of multiple anticonvulsants. Behavior problems abound and include autis- tic spectrum disorders, aggressiveness, and hyperactivity. EVALUATION—ETIOLOGY The differentiation of LGS from other catastrophic onset childhood epilepsies is important for prognosis and management. The seizure pattern may not appear char- acteristic initially and suggestive EEG patterns may not appear for several months. Therefore, it is not unreasonable to pursue diagnostic testing that may be suggested by the individual’s presentation—for example, that of progressive myoclonic epi- lepsy in a patient in whom the initial presentation includes myoclonic seizures. Very few patients with LGS, however, have documented abnormalities of metabolism. Concerns that LGS may be related to a developmental channelopathy or be an immune-mediated process have yet to be substantiated. In some series, 17–30% of patients with LGS have a history of infantile spasms. Therefore, central nervous system insults known to predispose to infantile spasms have been implicated in the pathogenesis of LGS. These include congenital infec- tions, sequela of neonatal hypoglycemia, hypoxic–ischemic encephalopathy, and traumatic brain injury. Lennox–Gastaut Syndrome 81 Structural abnormalities are the most common underlying etiology of sympto- matic LGS. Rarely, brain tumors have been known to cause LGS, although this raises the difficulty of differentiating true LGS from secondary bilateral synchrony. Tuberous sclerosis or other neurocutaneous syndromes are found in children with LGS, but not as frequently as in association with infantile spasms. Developmental brain malformations are the most common structural lesion to be reported in LGS, especially subcortical band heterotopia, bilateral perisylvian syndrome, and focal cortical malformations. It is therefore important to perform magnetic reso- nance imaging when considering the diagnosis of LGS, as there are reported cases of seizure reduction with focal surgical resection of lesions. Other types of neuroima- ging, including PET and SPECT scans, have not been uniformly helpful and are cur- rently better research than diagnostic tools. The majority of cases of LGS remain cryptogenic despite extensive metabolic evaluation and neuroimaging. Evaluation aimed at maximizing supportive care, such as neuropsychological assessment to identify baseline neurodevelopmental state and aid in appropriate educational placement are also important. It is helpful to differentiate LGS from other seizure syndromes, especially from myoclonic astatic epilepsy (Doose syndrome), that may have a more favorable prog- nosis. Children with myoclonic astatic epilepsy have the occurrence of multiple types of generalized seizures suggestive of LGS (i. However, it is always idiopathic, axial tonic seizures are rare or absent, onset is younger than in LGS (typically between 18 months and 4 years), EEG demonstrates photosensitivity, and there is a strong genetic predisposition. Prognosis for seizure control and devel- opmental outcome is more benign than in LGS. Similarly, an entity named atypical benign partial epilepsy of childhood occurs in children between 2 and 6 years, with prominent nocturnal partial seizures, myoclonic, and atonic seizures without tonic seizures. Electroencephalogram is remarkable for diffuse slow spike and wave in sleep and 3-Hz spike wave in the waking record. Seizures remit in late childhood in most patients and developmental regression is limited.

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When the Lady Chapel of the Liverpool The postgraduate course of orthopedic studies Cathedral was thronged with colleagues antimicrobial kitchen towel 500 mg arzomicin buy with mastercard, students was modified by insistence on preliminary and nurses antibiotic linezolid discount 250 mg arzomicin with mastercard, sharing with the bereaved family a general surgical training antibiotics for uti trimethoprim generic arzomicin 500 mg without a prescription, greater clinical respon- memorial service as simple yet dignified as he sibility, an introduction to clinical research, the himself would have chosen, the sun gleamed academic discipline of preparation of a thesis, and brightly through the stained glass window dedi- above all by the broadening of teaching to cated to service, at the foot of which rest the ashes embrace that of all his colleagues in Liverpool of Robert Jones. The luster It was to the Liverpool school of orthopedics and distinction he added to this historic school of and the traditions of Hugh Owen Thomas, Robert orthopedics will be treasured with pride and Jones and T. McMurray that McFarland dedi- affection by MChOrth graduates, not only in cated his life. Indeed the inspiration and magnetic Great Britain but in every nation of the British personality of Robert Jones shone through many Commonwealth and other countries throughout of his own qualities. He too showed open honesty with disdain unbounded energy, and devotion to duty such that of pomp and arrogance. His intuitive simplicity in recent years he was worried and anxious lest was a heritage of conservative philosophy broad- the ever-widening field of knowledge in basic sci- ened by awareness of new advance. With kind ences might not be reflected fully; still more was humanity he carried the torch of Robert Jones. One of his A true son of Liverpool, Bryan’s life was spent close colleagues has written: on Merseyside, first at the Wallasey Grammar School and then the medical school of the Uni- The present spirit of friendly cooperation between versity of Liverpool, where he graduated in Liverpool orthopedic surgeons is almost entirely of his 224 Who’s Who in Orthopedics making. He was the prime mover in forming the of the end, during a brief return of consciousness Liverpool Orthopedic Circle in 1944. The informal and and momentary recapture of the old sparkle, he frank discussion of cases which follows each monthly instructed his son how to secure and pack dinner of the circle has proved invaluable to its a Scotch salmon to fly back to his chief in members, not only in their work but in forming the America with whom he was working on a surgi- foundations of much closer personal friendships than cal fellowship. McFarland’s con- tributions to the discussions were typical of him, direct This tenacity and indomitable courage was and often pungent, and scorning all pretence and epitomized in his presidential address to the humbug. With McFarland at the head, the postgraduate Philomathic Society on “The Will to Live,” when school flourished. At long illness, beginning while lecturing to old stu- an early meeting, after two issues of the first dents in Australia, and ending so wearily that he British volume had been expensively published, was diffident in welcoming visitors lest he might we reviewed the balance sheet with dismayed not still seem steel blue and blade straight. With anxiety, and the board was informed that after gentle love, and no less firm endurance, he was months of endeavor, post-war controls had not yet sustained and comforted by his wife Ethel. He left been surmounted and there was no Board of Trade behind his wife and two sons John and Andrew. With a Bryan’s concluding words in his Philomathic chuckle McFarland said “ it seems to me that in address were: pursuing an illegal venture we face financial ruin—but we will go on. This feeling, the many councils and associations of which if unhindered by anxious thought, will grow in he became president, including the Liverpool strength; and when the troubled times are over we shall Medical Institution, University Club, Merseyside be just that little bit more balanced in judgment, that branch of the British Medical Association and little bit more determined in character, and that little bit Liverpool Philomathic Society. Of these little bits is built up our the Robert Jones Dining Club, which meets each national character which renders unconquerable our year after the eponymous lecture at the Royal land and invincible our soul. College of Surgeons of England—an oration that he himself gave brilliantly, as he did also the first McMurray Memorial Lecture in Liverpool. He prepared assiduously, for example taking coach- ing lessons in French to improve his continental duties, culminating in the presidency of the Société Internationale de Chirurgie Orthopédique et de Traumatologie. We chaffed him that his French was spoken with a strong Liverpool accent; but we loved him the more. He would leave home at three o’clock in the morning to arrive in Anglesey before dawn for wild-fowl shooting, and a superb shot he was. It was not until after the age of 40 that he became an enthusiastic fish- erman, but so thorough was the preparation and practice that he could equal the skill of any High- land ghillie at Cape Wrath. Within a day or two 225 Who’s Who in Orthopedics suade the giants of industry and commerce to con- tribute to the rebuilding and upkeep of the College. Archie, as he was affectionately known to all his friends, was a great plastic surgeon and teacher. But he was also the most likeable of men, with an infinite capacity for enjoying life in the company of every stratum of society. Honors were given to him in abundance but, though accepted with obvious delight, they never altered his delightful character. He will be greatly missed by his many friends and colleagues all over the world—and not least by his patients, especially the badly burnt Royal Air Force boys of the Second World War, who banded together to form the Guinea Pig Club, which met annually at East Grinstead under his presidency. Archibald McIndoe died peacefully in his sleep Archibald Hector McINDOE from a coronary occlusion on April 12, 1960, at the age of 59. Later he came to London and joined his cousin, Sir Harold Gillies, the great pioneer of plastic surgery, who outlived him by a few months.

Mortis, 40 years: Finally, there are a number of research initiatives focussing on alternative and complementary therapies that have been completed or are ongoing in Canada. Early the fol- of the Rector of Winterslow in Wiltshire, the lowing year his father died, leaving Mrs. London: group management in professional development and lifelong Kogan Page, 1999.

Ashton, 46 years: X Make sure you know how to get to the interview and arrive in good time. He had been a member of the British editorial board of The Journal of Bone and Joint Surgery, and traveled and spoke as a member of the British Orthopedic Travelling Club. He had education, and passed the final examination of the quite a mechanical turn of mind and designed an Conjoint Board in 1916.

Vibald, 37 years: Frank Dickson and Rex Divley and became interested in ortho- Harrison L. Example of clinical teaching session based on experiential learning cycle Setting—Six third year medical students doing introductory clinical skills course based in general practice Topic—History taking and physical examination of patients with musculoskeletal problems (with specific focus on rheumatoid arthritis); three patients with good stories and signs recruited from Experience Reflection the community The session Planning—Brainstorm for relevant symptoms and signs: this activates prior knowledge and orientates and provides framework and structure for the task Experience—Students interview patients in pairs and do focused physical examination under supervision: this provides opportunities to implement and practise skills Planning Theory Reflection—Case presentations and discussion: feedback and discussion provides opportunities for elaboration of knowledge Theory—Didactic input from teacher (basic clinical information about rheumatoid arthritis): this links practice with theory Planning— “What have I learned? Pugh is best remembered for his “traction by suspension” and for his “Carshalton carriages,” which were the tools he used to diminish the destructive changes so manifest in tuberculous joints treated without traction.

Folleck, 33 years: The outcomes for 18 hips of chronic/stable type included that the average postop- erative PTA for 11 hips after in situ fixation was 31°. The distinctive feature of this moral code is that it explicitly disclaims being a moral code. He tribulations of the illness that clouded his last five received the Order of Jamaica and was knighted years.

Konrad, 35 years: What is emerging is that researchers have assumed that memorisation was equated with mechanical rote learning. They showed that these titanium-containing zeolites are excellent catalyst for the selective oxidation of a variety of simple, small molecules. Olanzepine exhibits moderate to high affinity for D2, D4, 5- HT2A, 5-HT2C, and a-1-adrenergic receptors and also binds to D1 receptors.

Grubuz, 43 years: Ruth’s unexplained weight gain and especially her enlarged abdominal girth were a result of this problem. RECORD KEEPING 67 Always note any expression of non-compliance regarding discharge in­ structions, and your actions in response to this. He had great enthusiasm for this new method and devoted a major share of his time to developing the tech- nique and its application to clinical medicine.

Dimitar, 24 years: Albert wit and complete integrity, which made him Key was one of the 32 students who volunteered, respected and loved by innumerable friends in and, when the United States entered the war, he every walk of life. Informant preference to be inter- viewed in the home proved advantageous: in addition to allowing them to be more candid than in other locations, in the privacy of their homes many informants felt comfortable demonstrating various therapeutic techniques involved in the alternative health care they use. At this time the four eminent the American College of Surgeons to standardize authorities were Bloodgood, Coley, Ewing and hospitals in the United States.

Topork, 47 years: However, if the cysts invade the walls of the intestine, ulcers and diarrhea can ture collections are housed and maintained, usually by uni- be produced. The physical manipulations of mixing and purifying compounds can be automated to a large extent, and it is possible to imagine building a machine which could do the mechani- cal tasks of a highly trained synthetic chemist, although it would be far more expensive and probably less effective than a skilled individual. Facultative aerobes prefer the presence of oxygen but can adjust their metabolic machinery so as to grow in the absence of oxygen.

Gancka, 39 years: He perineal region, layer by layer, which is still a put forward his son Gabriel, who was a surgeon classic. Starting in September 2001, bioterrorist attacks with with certain nucleotides at the marker always have the disease, anthrax-causing bacteria distributed through the mail targeted and family members with other nucleotides at the marker do only a few U. Cowpox is a rare disease, and is mostly noteworthy as the basis of the formulation, over 200 years ago, of an injection by Edward Jenner that proved successful in CRANBERRY JUICE AS AN ANTI-ADHE- curing smallpox.

Akascha, 25 years: Some primary care residencies, including family medicine and general practitioner programs, may offer more training in functional concerns than others. However, you do not have to adhere rigidly to these during your interview. The dry In 1870, at a time when Mathijsen’s method of plaster, which was spread between the layers, treatment of patients was not generally known, remained two finger breadth widths within the Zola in his famous book, La Debâcle, described edges of the cloth.

Osmund, 36 years: Triple therapy with anti-retroviral drugs virtually eliminates the risk of transmission. On physical examination there is answers is easy and could be done with a computer. It is also extremely te­ dious for the student and does not promote active listening or critical thought.

Aidan, 56 years: Brute force methods of calculating new synthetic routes will not be fea- sible for a very long time, and pure literature based methods will also be very time consuming, and will be restricted by the data available. The final word – remember the effort and time you have put into preparing your dissertation needs to be rewarded with a good quality binder that does not fall apart in the marker’s hands. The interpretation of cervical spine radiographs may pose problems for the inexperienced.

Goran, 23 years: After joining the individuals who were the tenets in which he believed, he was continu- pioneering this adolescent discipline, his zeal ously involved in missionary work throughout the became readily apparent, and his natural talent as world. London: Imperial College Press, 2003: 84-89 Cross References Agrammatism; Agraphia; Alexia; Aphasia; Aphemia; Aprosodia, Aprosody; Paraphasia; Wernicke’s aphasia Brown-Séquard Syndrome The Brown-Séquard syndrome is the consequence of anatomical or, more usually, functional hemisection of the spinal cord (spinal hemisec- tion syndrome), producing the following pattern of clinical findings: ● Motor: Ipsilateral spastic weakness, due to corticospinal tract involvement - 60 - Bruit B Segmental lower motor neurone signs at the level of the lesion, due to root and/or anterior horn cell involvement. This nerve suture, and for acute suppurative arthritis was opened in 1919 and soon became one of the and gonorrheal arthritis.

Dudley, 65 years: Kerboull M (1996) Arthroplastie totale de hanche sur luxation congénitale. But before moving on, I must emphasize that all health-care settings are not yet fully and easily accessible, even those built after the ADA. Once you open the chakra, then you come back and touch that part of the chakra with your hand just gently and then do the fingers of the client and see if they’re still open.

Kalesch, 31 years: It also welcomed a mechanism for establishing more direct relations with citizens and thereby strengthening the authority of government over an increasingly fragmented society. Lucas, studies of the transmission the initiative and support of other American of the virus of poliomyelitis. He observed that when patients were asked what their expectations of treatment were, ‘almost without exception they stated that the principal reason for approaching services was to obtain “help”’.

Harek, 44 years: Mobility Limits / 3 These questions assume that getting out in the world is worth striving for, and that strategies exist to help us do so. Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Following the scandal of the high death rates at the Bristol children’s heart surgery unit (culminating in disciplinary action against three doctors in June 1998), the Kent gynaecologist Rodney Ledward (struck off the medical register in October 1998 for gross negligence), and numerous less grievous cases of incompetence or corruption, the Shipman case provided further impetus to the drive to tighten administrative control over the medical profession (Abbasi 1999).

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• Backman JT, Olkkola KT, Aranko K, Himberg JJ, Neuvonen PJ. Dose of midazolam should be reduced during diltiazem and verapamil treatments. Br J Clin Pharmacol. 1994;37:221-225.