睿学教育Wisdome Education

Mark D. Miller, MD

• S. Ward Casscells Professor, Department of Orthopaedics, University of Virginia, Charlottesville, Virginia

https://med.virginia.edu/orthopaedic-surgery/orthopaedic-faculty/mark-d-miller-md/

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Careful monitoring is essential for tetraplegic patients as cord oedema may result in an ascending level of paralysis allergy symptoms on lips discount 100 mcg rhinocort visa, further compromising respiration zopiclone allergy symptoms best order for rhinocort. Patients with tetraplegia or high level paraplegia may have paralysed abdominal and intercostal muscles and will be unable to cough effectively sulphate allergy symptoms uk purchase rhinocort without prescription. Careful coordination and communication between physiotherapist and patient is vital for assisted coughing to be successful. Forced expiration may be achieved by the placement of the therapist’s hands on either side of the lower ribs or on the upper abdomen and ribs, producing an upward and inward pressure as the patient attempts to cough. Two people may be needed to treat the patient with a wide chest or tenacious sputum. Good support must be given to the paralysed joints and a full range of movement achieved. All paralysed limbs are moved passively each day to maintain a full range of movement. Loss of sensation means that joints and soft tissues are vulnerable to overstretching, so great care must be taken not to cause trauma. Provided that stability of the bony injury is maintained, passive hip stretching with the patient in the lateral position, and strengthening of non- paralysed muscle groups, is encouraged. Once the bony injury is stable patients will start sitting, preferably using a profiling bed, before getting up into a wheelchair. This is a gradual process because of the possibility of postural hypotension, which is most severe in patients with an injury above T6 and in the elderly. Mobilisation into a wheelchair Once a patient is in a wheelchair regular relief of pressure at the ischial, trochanteric, and sacral regions is essential to prevent the development of pressure sores in the absence of sensation. Patients must be taught to lift themselves to relieve pressure every 15 minutes. Paraplegic patients can usually do this without help by lifting on the wheels or arm rests of their wheelchairs. Tetraplegic patients should initially be provided with a cushion giving adequate pressure relief, but may in time be able to relieve pressure themselves. Right: patient seated incorrectly—“slumped” and with poor Wheelchair design has been much influenced by technology. Footplates are too high so there is excessive pressure on Lightweight wheelchairs are more aesthetically acceptable, the sacrum—a potential pressure problem. An appropriate wheelchair should be ordered once an assessment of the patient’s ongoing needs has been made. Rehabilitation Physical rehabilitation includes the following: • Familiarity with the wheelchair. The patient has to be taught how to propel the chair, operate the brakes, remove the footplates and armrests, and fold and transport the Figure 9. Having first lifted legs up on to the bed the patient then ground and turning the chair. Hand position is important to achieve a safe lift, avoiding contact with wheel. The length of time this takes will depend on the degree of loss of proprioception and on trunk control. Teaching these skills is only possible once confidence in balance is achieved and there is sufficient strength in the arms and shoulder girdles. The degree of independence achieved by each patient will depend on factors such as the level of the lesion, the degree of spasticity, body size and weight, age, mental attitude, and the skill of the therapist. Patients who cannot transfer themselves will require help, and patient and helpers will spend time with therapists and nurses learning the techniques for pressure relief, dressing, transferring, and various wheelchair manoeuvres. The level of independence achievable by tetraplegic patients is shown on page 55 in chapter 10. Close cooperation between physiotherapists and occupational therapists helps patients to reach their full potential. Chair and legs must be sideways for manoeuvrability in a limited space; and lifting carefully positioned to ensure a safe lift.

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Friedrich TRENDELENBURG 1844–1924 Friedrich Trendelenburg was born in Berlin allergy testing risks buy 100 mcg rhinocort with visa, Germany allergy skin test results purchase genuine rhinocort online, where his father was a professor of phi- losophy and his mother was a teacher allergy testing glasgow buy 200 mcg rhinocort with amex. When his family moved to Glasgow, Jules TINEL Scotland, he continued his studies, and in 1863 1879–1952 began to study anatomy and embryology. Between 1864 and 1866 he studied medicine in Tinel was a French neurologist who wrote an various clinics, finally being granted his medical excellent book on the effects of nerve injuries degree by the University of Berlin. Such an edu- during the First World War, and from it one may cational background was not unusual in those judge how times have changed, for nerve suture days and medical students commonly studied for is hardly mentioned. He had a research interest in various periods at different institutions. After the autonomic system, producing a thick volume serving the required period in the army as a mil- on the subject; he was noted for the ingenuity of itary surgeon, Trendelenburg returned to Berlin his apparatus, which was often constructed of and came under the influence of the greatest Meccano. German surgeon of the period, Bernard Langen- He was born in Rouen, the fifth in a line of dis- beck. His father was professor of today, lasting from 1868 to 1874, Trendelenburg anatomy at Rouen. It was became a surgeon in an important Berlin hospi- when he was mobilized for the war that he found tal. A few years later he became the professor himself in a neurological unit and was able to of surgery in Rostock, Germany. His academic 333 Who’s Who in Orthopedics career flourished and included later appointment make full notes and to write long explanatory to the chairs of surgery at the universities of Bonn letters to doctors. He was an important leader in letters expressing Trethowan’s views on topical German surgery during the last half of the nine- orthopedic conditions (foot anomalies, abnormal- teenth century. He was the founder of the German ities of the back, disorders of the knee and bone Society of Surgeons and became its president. He popularized what has become these is almost to hear the fervent advocacy or known as the Trendelenburg position as an aid condemnation all over again. It is to be hoped that to performing pelvic and lower abdominal pro- this remarkably fine little book, containing the cedures. He raised the possibility of surgically views of one of the greatest, if not always the removing pulmonary emboli of large blood clots, soundest, of teachers will be reproduced. One recalls his outpatient sessions: there was He died of carcinoma of the mandible. His imitations of gaits in various orthopedic conditions can never be for- gotten by any who had the good fortune to be present. He maintained that the object of ortho- pedic surgery could be written on a thumbnail— function. Indeed, a house surgeon of his once said: “I would insist on Treth (as he was known to all) doing in my operation if Elmslie decided that an operation was necessary. His incisions were long, to enable him to see before he cut and to make it unneces- sary to use the sense of touch. He never ligated vessels, maintaining that if a surgeon exposed bone at its most superficial point and stayed close to bone, he was unlikely to cut any vessels of importance. He favored long intramedullary insertion of the graft at one end and a mortise fit to the circumference of the bone at the other. TRETHOWAN he was a greater technician in this field than 1882–1934 Albee, who was not embarrassed by adherence to a no-touch technique! Trethowan was a student of Guy’s Hospital At conferences he often favored the dramatic and was appointed its first orthopedic surgeon touch. He was one of Robert Jones’ team at discussion, probably on foot deformities, spring Shepherd’s Bush in World War I. After the war, to his feet brandishing a Thomas’ wrench and he joined the staffs of the Royal National exclaiming, “This is a barbarous weapon! His good friend Robert Jones for Children, Carshalton, and quickly established was not perturbed and let the remark pass with a one of the largest private practices in London. Trethowan was a generous friend He was a genius; but unfortunately he seldom and a remarkable host. Many writings were “The Treatment of Simple Frac- will recall parties at his Hampstead home where tures” in Robert Jones’ Textbook of Military in the billiard room he had installed an enormous Orthopedic Surgery (1920) and an article of organ. An able performer, he would begin to play singular clarity and brevity on orthopedics in perhaps at midnight and continue fortissimo well Choyce’s System of Surgery. He was a 334 Who’s Who in Orthopedics great figure, a most simulating chief, and a good The British Orthopedic Association presented friend.

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Articles can help to: ° increase the profile of your discipline in the public eye ° raise awareness of a particular condition or disease ° assist in educating the public about a healthy lifestyle ° focus on the causes and manifestations of specific ailments and the treatment options that are available ° provide information on a new treatment or a new type of service 302 ARTICLES FOR THE MEDIA 303 ° provide advice for readers on how to cope with the consequences of specific illnesses and the side effects of treatment ° boost fundraising by featuring a special event ° offer a forum for you to express a personal opinion on a topical issue allergy shots testing cheap rhinocort 200 mcg buy on line. Aspects of writing for the media Writing an article for the media differs significantly from writing an aca­ demic paper or journal article allergy treatment acupuncture purchase rhinocort 100 mcg with visa. Your readership will have limited knowledge and experience of the topic allergy medicine ok to take when breastfeeding trusted 100 mcg rhinocort. This will affect your choice of language and the type and amount of information you give. Messages given via the media have a greater impact than other forms of communication. It is essential that information is accurate, up to date and not alarmist. This will influence the content, style and perspective of the publication. Articles often take a certain slant or angle on a topic in order to attract the interest of specific readers. You need to consider this carefully when choosing a publica­ tion for your article. It is even more of a consideration when writing for magazines and newspapers. Planning, particularly for magazines, is usually done several months ahead. This needs to be taken into consideration if your work needs to be published by a certain date. This is not just about readers identifying the client, but also about the client being able to identify himself or herself. Before you get started you will need to have some basic ideas about: ° the subject or topic you want to write about (see Chapter 14 ‘Developing an Idea’ to help give you some inspiration) ° who you are writing it for (your intended readership) ° your market or where you might publish (local or national newspaper, weekly or monthly magazine, generalist or specialist journal) ° whether you will supply illustrations (see Chapter 18 ‘Presenting Your Work’ on the use of illustrations). You are more likely to be successful if you write your article for a specific magazine or newspaper – so before you finalise your idea, try to identify the most appropriate publication for your needs. Finding a market Each newspaper or magazine is designed, written and presented in a way that will attract certain groups of the population. Many will have a national distribution and contain articles and features of interest to a broad section of readers. There are also many specialist publications that maintain a small but well-defined readership. All these things need to be taken into consideration when deciding which newspaper or magazine you would like to approach. For example, a local or regional newspaper may be a better choice if you are hoping to do some fundraising for health provision within your local community. An ar­ ticle on health promotion would receive a greater audience in a national paper. You can find out more about the aims, content and readership of vari­ ous newspapers and magazines by consulting one of the directories or guides on this subject. The following books provide a wealth of informa­ tion about the market in these media: ° The Writer’s Handbook ° Willings Press Guide ° Writers’ & Artists’ Yearbook. ARTICLES FOR THE MEDIA 305 They will also give you information about which publications will con­ sider freelance contributions. Some major newspapers and magazines ei­ ther use in-house staff or only commission pieces from established journalists. Seek out those publications that have indicated that they con­ sider external contributors. Supplement information from the above guides by doing your own re­ search. Make sure that you have read at least three recent issues of the pub­ lication. For instance, one magazine may be interested in alternative or unusual health remedies, whereas another may favour a more traditional account of treatment and therapy. Monthly or quarterly magazines usually have longer and more in-depth articles than weeklies. Compare how the same topic is treated in different publications: ° What aspects of the topic have been highlighted? Another may choose to take a more upbeat approach, and focus on how families can recognise and help adolescents who have a drink problem.

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For instance allergy medicine nasacort rhinocort 200 mcg purchase without prescription, the people I spoke with would welcome inclusion of alternative therapies under public health insurance to the extent that it would help them overcome the barriers they face in accessing these forms of health care allergy medicine brands names purchase rhinocort without prescription. These barriers include a lack of financial resources allergy treatment side effects buy generic rhinocort line, a lack of information about alternative and complementary therapies, a lack of support from health care professionals, and stigma. That a lack of financial resources constrains access to these therapies is evidenced by the fact that Canadians spend between 1. A lack of information about what kinds of therapies are available is another significant barrier to access for people who would like to use alternative therapies. While some therapists are members of professional bodies and/or are listed in directories or registers, most of the alternative and complementary therapists consulted by the people who took part in this study are not. Similarly, medical and other health care professionals are unlikely to be able to provide information about these 120 | Using Alternative Therapies: A Qualitative Analysis therapies. In addition, the labelling of people who use alternative therapies as deviant both limits their access to these therapies and mitigates against achieving complementary health care. To the degree that their allopathic health care professionals collude in this labelling process, inclusion of these therapies within Canada’s mainstream health care provision would reduce the stigma associated with participation in alternative therapies and encour- age physicians to be supportive of their use, thus improving access. Likewise, inclusion would remove the barriers of cost and improve access to informa- tion about these approaches to health and healing. Finally, inclusion of alternative and complementary therapies within Medicare would show that health policymakers are responsive to the needs and desires of Canadians (WHO 2000). Furthermore, integration of allopathic with alternative healing approaches and inclusion of alternative therapies within Medicare would enable the people who took part in this research to address health problems for which they found no redress prior to their participation in alternative forms of healing. Finally, given these informants’ alternative model of health’s emphases on prevention, and its orientation towards chronic conditions, integration of alternative and allopathic healing paradigms would also positively affect population health and enable the Canadian health care system to better cope with the incidence of chronic illness. Notwithstanding these positive consequences, it is important to consider the ways in which integration of alternative and allopathic healing ideology or inclusion of alternative therapies within mainstream health care provision may not necessarily be entirely desirable. For instance, Glik (1988:1205) argues that “Attempts to ‘medicalize’ healing practices by employing them in clinical contexts may rob these practices of their effectiveness. Such standardization would result in reduced efficacy of alternative therapies according to these informants’ alternative model of healing, under which Conclusion | 121 the effectiveness of a therapy is due in part to individualized treatment regimes. In particular, it would likely divest their alternative model of health of its power to heal the self, one that lies in their perception of the distinc- tiveness of their alternative definition of health from biomedical under- standings. Inclusion of these therapies within Medicare would also interfere with how the people I spoke with use alternative therapies by constraining their ability to self-prescribe, experiment, and dabble in alternative therapies, as these approaches to health and healing would then be subject to the same gate- keeping practices as allopathic interventions. Furthermore, to the extent to which inclusion depends on scientific evidence of efficacy and medically rational explanation, some alternative or complementary therapies that “work” may remain “unproven. It is noteworthy, therefore, that many of the therapies used by these informants, including those they found most effective, are not found amongst those endorsed by the Western medical community. Finally, among the potential negative consequences of the efforts of alternative practitioners to become regulated professionals is that they may no longer have the power to challenge institutionalized biomedicine. Furthermore, the integration of alternative and allopathic approaches could rob the former of its ability to serve as a catalyst for innovation within mainstream health care provision. In Stambolovic’s (1996:603) words, “it is so important to nurture heresy’s imperfection, [especially] those parts that leave room for inquiry and change. Due care should also be taken that regulation of alternative therapies reflect these individuals’ desire to take control of their healing 122 | Using Alternative Therapies: A Qualitative Analysis process, which they accomplish, in part, through the freedom to experiment with alternative therapies. For example, in discussing a proposed bill that would include Vitamin C under the controlled substances act, Nora told me this: If they outlawed alternative medicine, would you stop using it? Would you strategize around how to get access to things that will become illegal...? I’d break the law if it was against the law because I think my health is my business and because it might be that my whole life or my whole being depended on that. It has to do with my health, so I really do think that when the state interferes and things like that it is never about protection; it’s about control. Similarly, where assessing the safety of these therapies is concerned, policy- makers should note that “the truth is that most therapies have direct risks and side effects” (Ernst 1997:43, emphasis mine). For example, in response to the headline: Patient Dies of Alternative Cancer Remedy, in the British Medical Journal (Gottlieb 2001), Lade (2000:1491) wrote as follows: “Why not make a headline such as: 10 000 people died from complications of cancer this week even though they had the standard conventional treatment. Therefore, Health Canada would do better to broaden its scope to address the safety of all interventions, whether alternative or allopathic, rather than focus exclusively on the safety of alternative therapies (Balon et al.

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Lynn always told me how grateful she was to me for my help with her mys- tery maladies allergy symptoms treatment order rhinocort overnight delivery, and I realized there were many people who had helped me as well new allergy treatment 2012 buy 200 mcg rhinocort otc. As I helped her with my medical knowledge allergy partners asheville nc order 200 mcg rhinocort amex, she helped me with her experience and understanding of how to get through my own crisis. Of course, I could hardly begin to express my profound gratitude to my fam- ily—my wife, my children, and my sister (who is a dentist and replaced every silver filling in my mouth in case those fillings were the cause of my prob- lems). All of them have been right by my side through everything, and we are an extremely close family. I remember walking into his office ‘loaded for bear’; I was angry and wanted to know what the heck he was going to do for me. When I entered his office, I found a man with no arms who was taking notes on my case with his feet. It humbled and reminded me that even with my mystery mal- ady, I had a lot to be grateful for! There were many times during the writing of this book when Lynn and I would howl with laughter about what cripples we were—she couldn’t sit and I couldn’t see. To date, Jerry has not been able to get the correct diagnosis, but he has gained some symptomatic relief. His armor was shattered, but in its place, he has emerged a more whole human being. He is much more in touch with who he is and his value as a human being without the need for the white coat. The Corporate Practice of Medicine: Competition and Innovation in Health Care, by James C. Experiencing Politics: A Legislator’s Stories of Government and Health, by John E. Deceit and Denial: The Deadly Politics of Industrial Pollution, by Gerald Markowitz and David Rosner 7. When Walking Fails: Mobility Problems of Adults with Chronic Conditions, by Lisa I. In the Fund’s own publications, in reports or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect the opinions or factual determinations of the Fund. University of California Press Berkeley and Los Angeles, California University of California Press, Ltd. London, England © 2003 by the Regents of the University of California Library of Congress Cataloging-in-Publication Data Iezzoni, Lisa, I. When walking fails : mobility problems of adults with chronic conditions / Lisa I. A To Reed Contents List of Illustrations and Tables ix Foreword xi Acknowledgments xiii Preface xv 1. Selected Resources 281 Notes 297 References 319 Index 335 Illustrations and Tables Photographs follow p. Reason for having no usual source of health care 135 x / Illustrations and Tables 13. Working-age people who did not get or delayed care in the last year 226 17. People with major mobility difficulties getting help with daily activities 269 Foreword The Milbank Memorial Fund is an endowed national foundation that en- gages in nonpartisan analysis, study, research, and communication on sig- nificant issues in health policy. The Fund makes available the results of its work in meetings with decision makers, reports, articles, and books. When Walking Fails is the eighth of the California/Milbank Books on Health and the Public. The publishing partnership between the Fund and the Press seeks to encourage the synthesis and communication of findings from research that could contribute to more effective health policy. This book is about statistics, health services, policy, and the experience of people whose mobility is limited as a result of chronic, progressive diseases or disorders. Lisa Iezzoni conducted more than one hundred interviews in preparation for writing this book. The stories she tells make her analysis of how clinical and financing policy could improve the quality of life for mil- lions of people uncommonly compelling.

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This will enhance the development of From theory to practice knowledge allergy treatment energy 100 mcg rhinocort with mastercard, skills allergy treatment sydney buy rhinocort 100 mcg low cost, and positive attitudes in their learners allergy medicine losing effectiveness purchase 100 mcg rhinocort amex, and improve the next generation of teachers. Ultimately, this should result in better trained doctors who provide an even higher level of patient care and improved patient outcomes. Self-direction for lifelong learning:a comprehensive guide to theory and practice. Teaching and learning in medical education:how theory can inform practice. Educating the reflective practitioner:toward a new design for teaching and learning in the professions. The word curriculum has its roots in the Latin word for track or race course. From there it came to mean course of The planned curriculum study or syllabus. Today the definition is much wider and • What is intended by the designers includes all the planned learning experiences of a school or educational institution. Thecurriculummustbeinaformthatcanbe communicated to those associated with the learning institution, The delivered curriculum should be open to critique, and should be able to be readily • What is organised by the administrators transformed into practice. The curriculum exists at three levels: • What is taught by the teachers what is planned for the students, what is delivered to the students, and what the students experience. It is underpinned by a set of values and beliefs about what students The experienced curriculum should know and how they come to know it. The curriculum of • What is learned by the students any institution is often contested and problematic. Some people may support a set of underlying values that are no longer relevant. This is the so called sabretoothed curriculum, which is Three levels of a curriculum based on the fable of the cave dwellers who continued to teach about hunting the sabretoothed tiger long after it became extinct. In contemporary medical education it is argued that the curriculum should achieve a “symbiosis” with the health services and communities in which the students will serve. The values that underlie the curriculum should enhance health service provision. The curriculum must be responsive to changing values and expectations in education if it is to remain useful. Students Elements of a curriculum If curriculum is defined more broadly than syllabus or course of Education improves study then it needs to contain more than mere statements of clinical service content to be studied. A curriculum has at least four important Curriculum Health services communities elements: content; teaching and learning strategies; assessment Clinical service processes; and evaluation processes. Curriculum writers have tried to place some order or rationality on the “Symbiosis” necessary for a curriculum. From Bligh J et al (see “Further process of designing a curriculum by advocating models. A consideration of these models assists in Curriculum models understanding two additional key elements in curriculum Prescriptive models design: statements of intent and context. One of the more well known examples is the “objectives model,” which arose from the initial work of Ralph Tyler in 1949. According to this model, four important questions are used in curriculum design. The first question, about the “purposes” to be obtained, is Objectives model—four important questions* the most important one. The statements of purpose have x What educational purposes should the institution seek to attain? This was interpreted very narrowly by some people and led to the specification of verbs that are acceptable and *Based on Tyler R. Chicago: Chicago University Press, 1949 those that are unacceptable when writing the so called 5 ABC of Learning and Teaching in Medicine “behavioural objectives. A more serious criticism is that the model restricts the x To solve x To fully appreciate curriculum to a narrow range of student skills and knowledge x To construct x To grasp the significance of that can be readily expressed in behavioural terms. Higher order x To list x To enjoy x To compare x To believe thinking, problem solving, and processes for acquiring values x To contrast x To have faith in may be excluded because they cannot be simply stated in behavioural terms.

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Catheterisation allergy testing instruments cheap rhinocort online amex, either by the patient or carer allergy shots upset stomach cheap rhinocort online american express, requires careful preparation and teaching allergy queensland order 200 mcg rhinocort otc, to provide the physical and psychological support necessary. Coming to terms with loss of this bodily function is often one of the hardest outcomes of SCI that the patient has to accept. Female patients provide an even greater challenge in the achievement of continence, because of Figure 8. Long-term suprapubic catheterisation is now a popular method of management. It is sexually and aesthetically more acceptable, as well as reducing the risk of urethral damage associated with long-term urethral catheterisation. The presence of an • Prevention of infection, calculi and urethral trauma indwelling catheter does not prevent upper urinary tract • Appropriate fluid intake complications. If possible and practicable, intermittent self-catheterisation is considered one of the best methods of management. Careful control of fluids and a daily routine will be needed to maintain a dry state between catheters. Emptying the bladder by tapping and expression, using condom sheath drainage, is also an excellent method in Box 8. Part of the education is assisting the patient to adapt their Upper motor neurone lesion: chosen method into their individual lifestyle, as well as teaching • Reflex emptying—after suppositories or digital stimulation • May not need aperients if diet appropriate the patient what to do if complications such as autonomic dysreflexia arise. Lower motor neurone lesion: • Flaccid • Manual evacuation and aperients usually required but may be Bowel care able to empty, using abdominal muscles • Suppositories ineffective During the period of spinal shock, the bowel is flaccid, so it Education must not be allowed to overdistend, causing constipation with • Programme established to meet patient’s lifestyle overflow incontinence. An initial rectal check is made to 47 ABC of Spinal Cord Injury ascertain whether faeces are present; if they are, they should be Box 8. Very little bowel activity will be Consider expected for the first two or three days. Evacuation should be • Level of injury performed using plenty of lubricant, and with only one gloved • Pre-injury bowel pattern finger inserted into the anus. Trauma, including anal stretching • Diet/fluid intake • What previously helped defaecation and a split natal cleft, is possible if insufficient care is taken. The patient is taught to have an adequate fibre diet, and a high fluid intake to help prevent constipation. The use of aperients is kept to a minimum, especially in a patient with reflex bowel activity. Bowel management may be performed daily, or • Achieve regular bowel emptying by production of a formed stool on alternate days, depending upon the individual’s bowel at a chosen time and place pattern. The patient is encouraged to sit on a specially padded • Avoid leaks or unplanned emptying shower chair, so that bowel care can be performed over the • Avoid constipation and other complications • Try to complete bowel care in 30–60 minutes toilet, followed by a shower. Sometimes this is not possible due • Be as practical as possible to poor balance or preferred choice, and bowel management continues on the patient’s bed. Where possible, to promote independent care patients are taught manual evacuation if the bowel is flaccid, or suppositories are inserted and/or digital stimulation performed if they have a reflex bowel. Nurses have to recognise when patients are ready to discuss sexuality, and respond appropriately as this need is not always verbalised in the early stages, and often manifests itself only in indirect questions or sexual innuendo. Discussion should be encouraged and should include dispelling myths, exploring the patient’s new sexual status, looking at alternative methods, identifying practical problems; and advising on how to deal with them. Referral to medical staff, sexual health specialists and other agencies for further information and management, should be offered as appropriate. Boston: Jones and Bartlett Publishers, 1992 48 9 Physiotherapy Trudy Ward, David Grundy Physiotherapy assessment and treatment should be carried out as soon as possible after injury. During the early acute stage, care of the chest and paralysed limbs is of prime importance. Chest complications may occur as a result of the accident—for example, from inhaling water during diving incidents, from local complications such as fractured ribs, or from respiratory insufficiency caused by the level of the injury. Respiratory management Bilateral arm strengthening exercises must be done in supine position to maintain vertebral alignment. All patients receive prophylactic chest treatment, which includes deep breathing exercises, percussion and coughing, assisted if necessary. Patient has to lift and rotate in the wheelchair in and out of a car unaided. In patients subject to postural hypotension the vertical position must be assumed gradually, and patients may be helped by the use of an abdominal binder.

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After In 1884 allergy essential oils 200 mcg rhinocort buy fast delivery, a paper by Rodet on experimental infec- 288 Who’s Who in Orthopedics tious osteomyelitis was read to the Academy of Science in Paris by Bouley allergy medicine 5 year old rhinocort 100 mcg amex, one of its fellows allergy medicine late period buy rhinocort 200 mcg without prescription. It is the first recorded experimental demonstration of the disease now known as hematogenous osteomyelitis. César ROUX 1857–1934 César Roux, born March 23, 1857 at Mont-la- Ville, died December 21, 1934, in Lausanne. Roux was educated in the Lausanne schools and pursued medical studies in Berne from Silvio ROLANDO 1874–1880. After 1 year of study in Vienna, Prague and Halle, he became first assistant at Köcher’s clinic and L’Hópital de L’Ile. He With the publication of his article “Fracture de la rapidly achieved a reputation of an extremely base du premier metacarpien,” Silvio Rolando skillful surgeon. In 1887, he was asked to become became the third Milanese surgeon to have a frac- the physician in charge of one of the two surgical ture named after him, a distinction he shares with services at the regional hospital in Lausanne, and Monteggia and Galeazzi. Like his colleagues, in 1890, Roux was given a title of extraordinary Rolando was a general surgeon. During a period professor and in 1893, ordinary professor of of 30 years, he published papers in Italian and surgery. Roux knew how to incite students to French medical periodicals on a wide variety of observe and think. Rolando was a member of the and scientific activities lasted almost 40 years. Roux’s name is closely linked to important progress in modern surgery, especially in the treatment of typhlitis, an affliction that Roux named more pertinently appendicitis, and opera- tive treatment of recurrent dislocation of the patella. His operative methods represent important innovations (thoracoplasty in pul- monary tuberculosis, esophagojejunogastrosto- mosis in esophageal stenosis, posterior gastroenterostomy in Y-manner in gastric carci- noma, etc. There is practically no surgical inter- vention that Roux has not modified technically in 289 Who’s Who in Orthopedics an original manner. A great number of new instru- Raymond was an intern at the Hôpitaux de ments and apparatuses are attributed to him. In his Paris Medical School from 1952 to 1958 and, in later years, Roux was particularly interested in the 1955, he served as an aide d’anatomie de la goiter problem. It was during his internship that he had to choose between general surgery and orthopedics. He had been influenced by Patel, Couvelaire, Hepp, and Cordier in the former field and by Lence, Merle d’Aubigné, Petit, Fevre, and Judet in the latter. Having studied under the most important person- alities of that time, Robert Judet and Gaston Cordier, Raymond chose to remain in orthopedics with Judet. In 1957, Raymond presented his thesis on pseudarthroses of the long bones, which was based on his work as a member of the anatomy department. His thesis was awarded the Gold Medal, the highest honor that can be achieved by a graduate student. His findings related to the vascularization of nonunions were a major con- tribution to the understanding of the appropriate treatment of these lesions. On the basis of his work with Cordier in the anatomy laboratory of the faculté in 1959, he compiled an atlas of hori- zontal cuts of the thorax, with photographs and illustrations that demonstrated the axial anatomy: Raymond ROY-CAMILLE these images prefigured what would later be 1927–1994 possible with computerized axial tomography. After completing his internship, he spent a year Raymond Roy-Camille was born on April 25, in the service of Professor L. Leger was 1927, in Fort-de-France on the island of Mar- also from Martinique, and he took Raymond tinique. Raymond was an active, friendship that lasted for the remainder of their curious child and a serious student. His interest in trau- nated by the work of his uncle and spent much matology and tumors of the spine was particularly time visiting and observing him. He shared Judet’s He completed secondary school in 1945 after interest in the cervical spine, and his innovative having excelled in all of his classes. He established criteria these were the years of World War II, the educa- for the use of a posterior approach for the opera- tional system of Martinique was not disrupted. Raymond moved to France in 1945 at the age of He also described the importance of the midver- 17, just as the war was ending. When he arrived tebral segments and ligamentous injuries of the in Paris, there were continuing post-war restric- cervical spine.

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In cases with a very narrow A-frame notch allergy forecast map cheap rhinocort line, this will mean more extensive use of the burr to remove enough bone to visualize the back of the notch (Fig allergy shots not refrigerated cost of rhinocort. Measure the size of the notch with an instrument allergy pollen count cheap rhinocort 200 mcg without prescription, such as a pituitary rongeur that opens to 10mm. It is important to remove the soft tissue to visualize the back of the notch. The residents ridge does not have this fringe, so the physician should easily identify the correct area. Linvatec makes a southpaw for left knees that also eliminates the jumping. The author makes a small divot with the burr at the position that the tunnel should be, that is, 7mm in from the drop- off at 11 or 1 o’clock. The major mistake would be not to clear enough soft tissue to expose the posterior aspect of the notch. Tibial Tunnel Choosing the correct position for the tibial tunnel is crucial to the rest of the operation. The landmarks are external surface of the tibia, 4cm from joint line, 2cm medial to tibial tubercle; inside, 7mm anterior to the leading edge of the PCL, in the midline. The guide is inserted through the anteromedial portal, by turning it upside down. The distal point of the guide is positioned 2cm medial to the tubercle and 4cm from the joint line. If necessary, chamfer the posterior rim with the chamfering device on the drill. The wire is in the middle of the ACL stump, approximately 7mm in front of the PCL, in the midline and just touching the edge of the PCL. Femoral Tunnel To drill the femoral tunnel, the Bullseye (Linvatec, Largo, FL) femoral aiming guide is placed through the tibial tunnel. This means that the tibial tunnel must be in the correct position and at the correct angle or it will be impossible to place the femoral tunnel correctly. Femoral Tunnel 107 are drilled according to the graft measurement, that is, 7 or 8mm. The physician should not leave the graft soaking in saline, as it may swell and make passing difficult. The femoral tunnel is drilled through the tibial tunnel with the use of the femoral aiming guide (Fig. The Bullseye guide is inserted through the tibial tunnel, the flare of the guide placed over the top of the femoral condyle, and the guide aimed at the 11 or 1 o’clock posi- tion (Fig. A long, guide-passing wire is drilled into the femur and retrieved through the anterolateral thigh. The surgeon should avoid placing the femoral tunnel in a vertical position. Howell has shown that the vertical graft provides a-p stability, but not rotational stability at 30° of knee flexion. The oblique position of the graft is preferable to the vertical graft position. The guide wire (Linvatec, Largo, FL) is overdrilled with the same size C-reamer as used in the tibial tunnel. It is important to make a foot- print on the condyle by drilling only half of the head of the drill bit into the bone. The drill bit is retracted and the footprint examined to deter- mine if it is in the correct position (Fig. Tunnel Dilation Tunnel dilation is a method to compact the tunnel wall to improve the pullout strength of the interference screw. In the middle-aged patient, the tunnels should be dilated 2 sizes to improve the fixation strength. For example, if the graft is 8mm, drill a 6-mm tunnel and dilate 2 sizes. Drilling a small tunnel in both the tibia and femur and inserting the graft passing wire through both tunnels facilitates the dilation procedure. With the graft passing wire inserted, both tunnels can be quickly dilated with a single pass of the dilators (Fig. Tunnel Notching The edge of the tunnel must be notched to start the BioScrew (Linvatec, Largo, FL) (Fig.

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Instead allergy medicine nasonex order genuine rhinocort on line, the phage DNA is Refrigeration can be bacteriostatic for those bacteria that can- incorporated into the host cell’s chromosome where it is then not reproduce at such low temperatures allergy treatment therapy buy generic rhinocort 100 mcg line. Every time the host cell divides allergy pro buy rhinocort 200 mcg without a prescription, it repli- riostatic state is advantageous as it allows for the long-term cates the prophage DNA along with its own. Ultra-low temperature freezing and two daughter cells each contain a copy of the prophage, and lyophilization (the controlled removal of water from a sample) the virus has reproduced without harming the host cell. Another bacteriocidal tech- certain conditions, however, the prophage can give rise to nique is the storage of bacteria in a solution that lacks nutri- active phages that bring about the lytic cycle. Various buffers In 1915, the English bacteriologist Frederick Twort kept at refrigeration temperatures can keep bacteria alive for (1877–1950) first discovered bacteriophages. Twort iso- infectants; Laboratory techniques in microbiology lated the substance that was killing the bacteria and hypothe- sized that the agent was a virus. The significance of this discovery was not INFECTION appreciated, however, until about thirty years later when sci- entists conducted further bacteriophage research. Luria (1912–1991), BACTERIOPHAGE AND BACTERIOPHAGE an Italian-American biologist especially interested in how x rays cause mutations in bacteriophages. Luria was also the TYPINGBacteriophage and bacteriophage typing first scientist to obtain clear images of a bacteriophage using A bacteriophage, or phage, is a virus that infects a bacterial an electron microscope. Salvador Luria emigrated to the cell, taking over the host cell’s genetic material, reproducing United States from Italy and soon met Max Delbruck itself, and eventually destroying the bacterium. Most DNA phages have dou- the group of researchers that joined them studied the genetic ble-stranded DNA, whereas phage RNA may be double or sin- changes that occur when viruses infect bacteria. The electron microscope shows that phages vary scientists did not know which part of the virus, the protein or in size and shape. Filamentous or threadlike phages, discov- the DNA, carried the information regarding viral replication. It was then that scientists performed a series of experiments Scientists have extensively studied the phages that infect using bacteriophages. Some of these phages, such as the T4 phage, the Watson and Crick model of DNA explained how DNA consist of a capsid or head, often polyhedral in shape, that con- encodes information and replicates). For their discoveries con- tains DNA, and an elongated tail consisting of a hollow core, cerning the structure and replication of viruses, Luria, a sheath around it, and six distal fibers attached to a base plate. Delbruck, and Hershey shared the Nobel Prize for physiology When T4 attacks a bacterial cell, proteins at the end of the tail or medicine in 1969. In 1952, two American biologists, fibers and base plate attach to proteins located on the bacterial Norton Zinder and Joshua Lederberg at the University of wall. Once the phage grabs hold, its DNA enters the bacterium Wisconsin, discovered that a phage can incorporate its genes while its protein coat is left outside. The phage genes are then Double stranded DNA phages reproduce in their host transmitted from one generation to the next when the bac- cells in two different ways: the lytic cycle and the lysogenic terium reproduces. During the Sanger, was awarded a Nobel Prize for determining the lytic cycle in E. He started graduate work at the ing, manipulating genetic molecules for practical uses. During Massachusetts Institute of Technology (MIT), but he trans- genetic engineering, scientists combine genes from different ferred after one year to the Rockefeller Institute, now the sources and transfer the recombinant DNA into cells where it Rockefeller University, in New York. Franklin, a molecular biophysicist specializing in host because they can grow it easily and the bacteria is well RNA viruses. One way to transfer the recombinant DNA to cells uti- completed three years postdoctoral research at the Salk lizes phages. Employing restriction enzymes to break into the Institute in La Jolla, California. There he met Renato phage’s DNA, scientists splice foreign DNA into the viral Dulbecco, who developed innovative techniques for examin- DNA. In addition, bacteriophages provide infor- collaborated in some of his viral research, and later became a mation about genetic defects, human development, and dis- full professor at the Harvard Medical School. One geneticist has developed a technique using Baltimore joined the MIT faculty, became full professor in bacteriophages to manipulate genes in mice, while others are 1972, and in 1973 was awarded a lifetime research professor- using phages to infect and kill disease-causing bacteria in ship by the American Cancer Society. In addition, microbiologists found a filamentous bacte- Prize in 1975 Baltimore continued to be honored for his work. In the mid-1970s Baltimore turned to research in molec- ular immunology, establishing a major presence in that rapidly See also Bacteria and bacterial infection; Biotechnology; Cell developing field.

Kent, 31 years: Many false-localizing signs occur in the clinical context of raised intracranial pressure, either idiopathic (idiopathic intracranial hypertension [IIH]) or symptomatic (secondary to tumor, hematoma, abscess). Sugano N, Atsumi T, Ohzono K, et al (2002) The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. Others, like enzymes, a class of active (cat- nucleotide base pairs: Adenine-Thymine (A-T or T-A) in con- alyst) proteins, promote essential biochemical reactions, such trast with amounts of Guanine-Cytosine (G-C or C-G). Ensure that the patient is on his or her back and lying on a firm, flat surface, then start chest compressions.

Charles, 26 years: Incontinence of neu- rological origin is often accompanied by other neurological signs, especially if associated with spinal cord pathology (see Myelopathy). Private health plans typically cover acute medical and sur- gical hospitalizations and primary and specialty physician visits but differ widely in coverage for other services. Though these movements expressed an individualistic and consumerist perspective, both were associated with wider goals of personal and social liberation. When they ask me why, I say because I do not like to shave, but actu- ally I do not like to look at myself in the mirror.

Ur-Gosh, 28 years: Also, in trying to keep an open mind and thinking about my belief systems, there is a slight possibility that the symptoms do not indicate a dis- ease or condition, which is why I can’t find a diagnosis; maybe they are a side effect of some medication. Patients who carry out manual evacuation are advised to keep their stools slightly constipated to ease removal. The later growth of fundholding practices gave a further boost to the employment of counsellors in the surgery. It is Required rehousing, patient or family bought property 5 therefore important for those working with disabled people to be aware that they may be underclaiming benefits and to advise them accordingly.

Fraser, 45 years: Conduction aphasia is most often seen during recovery from Wernicke’s aphasia, and clinically there is often evidence of some impairment of comprehension. Eventually, they de- cide to knock on each door on the estate and ask some simple, standard questions. When grown on a solid agar Hence, the genetic message is transcribed to a messenger, and surface, the colonies of such strains appear like mucous drops. The resuscitation and growth of Bacillus thuringiensis within Examples of bacteria that are most commonly associ- the insect gut kills the larva.

Tamkosch, 21 years: Audit Commission (1993) What Seems to be the Matter: Communication Between Hospitals and Patients. X-ray findings at 57 years of age, preoperative (A), and at 72 years of age, 15 years postoperative (B) After the first stage of the operation was completed, the leg was pulled distally and the adjusting down of the femur was accomplished (Fig. It has been documented that exercise produces laxity of the ACL, but there are no significant differ- ences in gender. The prevention of contamination during the bacteria, interrupting the mating process.

Spike, 30 years: These policies did not involve any redistribution of resources to the poor (the anathematised tradition of Old Labour); in practice, they meant more intensive measures to push people into the labour market and schemes to foster healthy lifestyles and parenting skills— which is where GPs come in. It follows nondominant (right) hemisphere lesions and may accompany emotional dysprosody of speech. Cases of dysplastic hip, Crowe III and IV, treated with enlargement in 1987 to 2003 Limb shortening (preoperative): 20–70mm (mean: 44. The weight of the transparency should prevent the paper from moving or falling away.

Marius, 32 years: The earliest appointment with the university health services neurolo- gist was on Wednesday during final examination week, right before Christmas. In those It mattered little that he never occupied a resi- days, the fracture was the Cinderella of surgical dent hospital appointment, or that he was osten- practice. A journal article or other written material (an interesting example is provided by Moore where he used extracts from literary works to help students understand the broader cultural, philosophical, ethical and personal issues of being a doctor. It can be hard to take an overview of the contents when you are deal­ ing with so much information.

Rhobar, 50 years: His recent initiatives using magnetic stimulation have been the first series of experi- ments to use the technique to study cognitive processes. The reason Ellen felt better during the short time she was going to the gym was because endorphins were probably being released after her vigorous exercise routine. Louis Lichtenstein, by original geons, New York Medical College, and Albert description or redefinition Dr. Despite the presence of the virus in saliva, it does not seem that transmission occurs via this route in the absence of blood to blood contact.

Arokkh, 59 years: All we can do here is urge caution, use good-quality test items, and to always ensure that students receive helpful feedback on their learning. Two of the most useful systems developed were discovered by Tom Pinnavaia of Michigan State University. Aside from the common side effects of steroids such as psychosis, GI bleed- ing, hypertension, and hyperglycemia, steroids can have the unintended effect of decreasing BBB permeability and can interact with chemotherapeutic agents, increasing toxicity and=or decreasing efficacy. You’ll find that most people are uncomfortable during silences and will elaborate on what they’ve said rather than experience discomfort.

Nefarius, 42 years: Six obstetricians turned away one woman wheelchair user before a seventh agreed to de- liver her baby. For example, a researcher might be interested in finding out whether women aged 40-50, in professional occupa- tions, are more likely to try complementary therapies than younger, non-professional women and men from all categories. Michael Fitzpatrick concludes that doctors should stop trying to make people virtuous. They provide a framework that makes it easier to assimilate new informa­ tion with what you have already learnt.

Umbrak, 56 years: Only if each component is very clearly defined and readily observable can a checklist be reliable. In 28 hips with equal to or greater than 25% of postoperative LHI, 24 (86%) hips showed good or excellent results. For many of my patients, the prospect of prolonging their stay in a world that has little time or respect for them has little appeal. For instance, in documenting the usage of | IX alternative and complementary therapies in the United Kingdom (UK) and internationally, Fulder (1996:xii) refers to “the United States, Western Europe, Germany, France, The Netherlands, the rest of Europe and Scandinavia,...

Sinikar, 54 years: If you want the students to undertake some reading, then consider the following points: What are students expected to achieve by undertaking the reading? You’ll find that most people are uncomfortable during silences and will elaborate on what they’ve said rather than experience discomfort. Spinal the bowel is intubated via the stoma, and a large volume enema Cord 1999;37:211–14 (e. After an Right up to the very end of his life, he was illness lasting 2 months, he died on May 21 at the working intensively for patients and in the field age of 76 years.

Asam, 29 years: Have they the time to read through reams of quotations or are they interested only in conclu- sions and recommendations? In Britain, however, some medical resistance to the concept of ‘nicotine replacement therapy’ was reflected in the decision not to make it available on prescription, either in the form of chewing gum or the more ‘medical’ skin patches. The MG can manifest over a range from trivial to cata- strophic; the course can be stable and predictable or extraordinarily capricious. Jean VERBRUGGE 1896–1964 Henk VERBIEST The Belgian medical world, and especially its 1909–1997 orthopedic surgeons, mourn the passing of an eminent surgeon, a good man, and an incompara- Henk Verbiest was born in Rotterdam in 1909.

Cobryn, 53 years: Again pictures and symbols may be used to represent ideas rather than words. Breathe Attempt rescue breathing if there are no signs of effective spontaneous respiration or if the airway remains obstructed. Kidner contributed extensively to orthope- dic literature throughout his active life. The meniscus tear should be repaired early and, in some situations, the ACL reconstruction should be delayed until a good range of motion has been achieved after the meniscus repair.

Mojok, 65 years: I noted above that two of the problems with the lesion technique in patients and non-human primates were that the process could not be reversed and information about time was lost. Chiari II Malformation and Myelomeningocele This group can be very challenging to manage due to the complexity of the myelo- meningocele patient. His long interest in medicolegal issues soon led him to the Stetson University School of Law in De Land, Florida, where he taught for 26 years and became the Uni- Irwin S. Wangensteen OH, Wangensteen SD (1978) The Rise that the institute in Montpellier was founded.

Karmok, 55 years: Placement of these artificial means for alimentation do not preclude bottle or even breast feeding for those infants who are able to do so, but alleviate the difficulties with maintaining minimum caloric support that frequently develop over time. Microscopic examination of bacteria found in the of the information that has been obtained has come from the mouth has also revealed S layers. In this chap- ter, we will outline the Eight Step method designed to help you become your own medical detective. He is, dic career, Vainio drew fundamental guidelines perhaps, best remembered for his description of for the operative treatment of the rheumatoid spinal stenosis.

Kelvin, 62 years: Their analgesic effects occur as early as 20 min following ingestion and reach a maximum at 60–120 min; their plasma half-lives of elimination are 2. The next step was the appointment of a group As more and more men became interested of foreign editors who kept Dr. The categories include everyone in the sam- ple, no one should fit into more than one category and the implication is that no one category is better than another. Though this comparison was designed to reinforce the pernicious character of nicotine, it also implicitly undermined the wider concept of addiction: after all, if millions of people have managed to quit smoking and overcome the demon nicotine, perhaps the grip of heroin and cocaine is not quite the overwhelming compulsion it is often made out to be.

Alima, 35 years: The possibility of increased intracranial pressure contributing to worsening of symptoms must always be considered. But everybody has secret hopes and expectations that, over time, bump up against reality, and I certainly never expected not to walk. As a teacher, Outerbridge enjoyed the personal Sir James PAGET contact with his students. You must 146 HOW TO BE AN ETHICAL RESEARCHER/ 147 try to minimise the disruption to people’s lives and if someone has found it an upsetting experience you should find out why and try to ensure that the same situation does not occur again.

Hogar, 57 years: He claimed that this approach had ‘led to indifference to the external influences and personal behaviour which are the predominant determinants of health’ (McKeown 1979:xvi). In this paper, we shall explain the basic science and technology underlying the chemical vapour deposition of diamond thin films, and show how this is leading to the development of diamond as a twenty-first century engineering material. Adapted from Resuscitation Guidelines 2000, London: Resuscitation ventilation is continued at a rate of about 12 ventilations per Council (UK), 2000 minute. In The Treatment of until the time of his death (1959), he was distin- Pes Cavus (1921), he analyzed the muscle imbal- guished service professor emeritus of the univer- ance that produced claw foot and advocated the 319 Who’s Who in Orthopedics correction of the severe skeletal deformity by of the wrist and the fingers.

Arakos, 23 years: These surgeons faithfully each several fibre, the reticular structure possesses passed on the teaching of Professor Watanabe to great strength as a whole. Brenner is known for his aggressiveness, intelli- most fundamental chemical processes of life, and now he gence, flamboyance, and wit. These periodic reviews of the content help consolidate the reader’s understanding and add emphasis to the writer’s message. An ingeneous method to circumvent this problem was first devised by Zewail and colleagues, who took advantage of the vibrational and rota- tional cooling properties and collision-free conditions of the supersonic 12 G.

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