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As to an iatrogenic cause buy 50mg minocin with mastercard antibiotic walmart, while the literature did not indicate priapism as a side effect of either Rogaine or the cholesterol medication minocin 50 mg amex antibiotics for acne list, Dr. He had already discov- ered firsthand that literature from drug manufacturers may be skewed for obvious reasons. The Physician’s Desk Reference (PDR), which is a leading drug reference among not only physicians but millions of consumers, is mainly a collection of package inserts written by drug companies and as such may omit or underreport serious side effects of medications. Pitman should both get on the phone and call any and every doctor they could think of, in the hope of 110 Diagnosing Your Mystery Malady finding one who might have heard similar complaints from a patient who was using either Rogaine or the cholesterol medication. Pitman spoke with an endocrinologist who had a friend—not a patient—who had experienced erectile dysfunction from the same choles- terol medication that had been prescribed for Dr. Rosenbaum that he would stop the medication as an experiment and see if it made a difference. Pitman’s symptoms did not disappear after he refrained from motorcycling, nor did they reappear after he discovered what he believed was the source of his condition. His mystery malady was indeed an unlisted and per- haps unrecognized side effect of that particular medication. He consulted his internist to prescribe a different medication to lower his cholesterol. Pitman’s case, four factors contributed to a successful outcome: working through the Eight Steps, keeping an open mind, talking to every physician he could about his problem, and a willingness to experiment and test his hypothesis by eliminating certain factors to observe whether this made a difference. Case Study: Rosalind Another medical practitioner, surgical nurse Rosalind, went through a less formal, deductive reasoning process to find the answer to her medical mys- tery. While not illustrative of the Eight Step method per se, it is a prime example of how things that might be healthy for some are unhealthy for *At the time, Internet bulletin boards or websites were not as popular, but these are poten- tial resources. They should be considered one source to be verified along with all other information gathered. See Chapter 5 for more tips on using the Internet for medical detective work. Approximately five years ago, Rosalind called in sick when she began having intolerable pain in her right side adjacent to her stomach. Being a surgical nurse, she thought the source of her pain might be her gallbladder because she had three of the “four Fs” likely to point to such problems— female, fair, fat, and over forty. She consulted the doctor in the women’s health center of the hos- pital in Reno where she worked. The doctor told her to change her diet anyway to eliminate fatty foods, which can play a role in gallbladder aggravation. Rosalind followed the doctor’s orders and lost a couple of pounds but had no relief from her pain. Her doctor then ordered an upper gastroin- testinal series, which also had normal results. He was a wonderful and sympathetic physician, and after treating her with the usual antacid med- ications like Prilosec and Prevacid for several weeks with no results, he began to get concerned that he had missed something. This is a procedure in which she would swallow a camera for the doctor to observe her gastrointestinal tract. When she did, he couldn’t see anything of significance except a mild irritation of Rosalind’s stomach lining. Satisfied that there was nothing seriously wrong, he gave her a diagnosis of gastritis. Rosalind was hesitant to call him again two weeks later with the same complaints, but when she finally did, he suggested that her problem might be stress-related since that is often a major factor in digestive disturbances. So Rosalind scheduled a vacation with her grown son, his wife, and their small son who lived in Oregon. They all went to a wonderful bed and breakfast on the southern coast, and a few days into the vacation, Rosalind began to feel better. Ten days later, she returned home feeling wonderfully relaxed and healthy.

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Never was a staff of girls but her treatment of me as a cripple was beyond more able buy discount minocin 50mg line infection in finger, more happy buy minocin 50 mg low price antibiotic resistance threats in the united states cdc, and more ready to give praise. My brothers and sisters It was in Rhyl, on the sea-coast of North Wales, were never made to fetch and carry for me, and I that two fundamental principles of the nursing joined in their play. The Royal Alexandra Hospital was pledom and the great education of pain”; she was perhaps the first hospital for cripples ever to advo- destined to limp her way through life with stick cate fresh air as an integral part of treatment; and or crutch; but already she had learned a first prin- it was the teaching of Miss Graham, one of the ciple—the joy of life despite disability—and this founders, that “no nurse is worth her salt if she was to be her great contribution to medicine. She was awarded the Agnes knew that “you might as well try to stop queen’s badge and brassard, and spent a year in Niagara as stop my mother when once she had Northamptonshire nursing a typhoid epidemic. Hunt decided to return as a district nurse in treating 500 victims of a to England, Agnes Hunt decided to stay in smallpox epidemic. She was In 1900, “mother broke it to me that she was influenced in this decision by an accident sus- becoming old and deaf and intended to live with tained by a young man who was felling trees. He no more travel and there could be no more respon- was found dead 2 months later and from the sibility as a district nurse. But, on reflection, this marks on his wrist he had tried to gnaw his hand indomitable girl realized that it might still be pos- off. Training as a nurse began as lady- preventive treatment, and resettlement of the dis- pupil at the Royal Alexandra Hospital in Rhyl, abled. Now, in 1948, the vast resources of the 148 Who’s Who in Orthopedics Ministry of Health and the Ministry of Labour are cars had recently been introduced; the roads of engaged in the treatment and resettlement of Shropshire were narrow; and the Baschurch nearly one million disabled persons. Bobby met hospitals and after-care clinics have been estab- Jonathan Hustler’s new car with its rush and hoot lished throughout the country. The beginning was: “mother intended with his precious load, and off he set in the middle of to live with me. The road was narrow, the road was long; country house with an estate of no more than Jonathan’s language grew very strong. The neighbours laughed to see the sight; Bobby drainage was primitive; the garden was so run-riot looked neither to left nor to right; till the dray and the that it was a jungle and became known as the whole of its cripple crew, safely back to the home he lion’s den; there were a few cowsheds with drew. When Jonathan started out that day, he swore that broken walls and leaking roofs—this was the nothing should bar his way, though police traps in every Baschurch Convalescent Home. The sheds were more damp and Three years later, recurrence of infection in the draughty within than without, so that open-air hip joint made it necessary for Sister Hunt to treatment was quickly enforced. An editorial, signed by Brother Aaron, One day, soon after I had returned from the Royal reads: Southern Hospital and was still on a frame, I drove the black cob in the dray to Shrewsbury to do my What causes the most excitement is the picnics. I had several cripples with me, the cripples on drays with springs and the others on one of whom was disabled only in the arm and could wagonettes. When we have reached the spot planned, climb on and off the vehicle to ask the shopkeepers to the horses are taken out and fastened to the trees and come out. As luck would have it the cob was restive all the cripples who can’t get about are put on rugs. Those on crutches play as well but ment that adds to one’s dignity and the bobby’s only they are far more artful for when they are about a yard answer was that he considered it unsafe and must take off the base they suddenly drop; of course the crutches my name and address. I told him, and thinking to reach it if they don’t and they are let stand up as if they impress him added that I used to live at Boreatton Park. All sing until they have hardly Unfortunately he knew this place only as a private any breath left to sing the National Anthem. The people lunatic asylum; my brother had let the house for that in the cottages all come out and by the look on their purpose some time after my father’s death. The police- faces we could almost believe they wished to be ill just man remarked acidly that it was just the sort of place for the sake of the picnics. There were picnics to the country and picnics This association with Robert Jones was a mile- to the seaside. The famous pony, Bobby, “the stone by which the Baschurch Convalescent dearest and wickedest of ponies,” made history Home became an orthopedic hospital. McCrae for himself when he was so often left in sole Aitken was at that time house surgeon at the charge of a cargo of cripples. Sir Frederick Royal Southern Hospital, Liverpool, and he Kenyon recorded an incident in verse. Motor wrote: 149 Who’s Who in Orthopedics There arrived from time to time in the out-patient theaters, which are essential features of a modern clinic, a woman, an outside porter from the railway hospital, became available. Consultants visit from station, and a homemade handcart like a baker’s tray Liverpool, Manchester, Birmingham, Cardiff, on perambulator wheels.

He was assis- surgical officer in Mansfield order 50 mg minocin visa infection bio war, Nottinghamshire discount 50mg minocin with visa antibiotics libido, tant to Dumreicher at Innsbruck and 10 years later where he remained for the rest of his professional was appointed to succeed him as professor of career. The last is a classic description of the the treatment of injured miners. His next step was results of a very large series of fractures treated to develop a rehabilitation unit for miners at Berry conservatively and remains a benchmark against Hill Hall, near Mansfield. It was very much “Nick’s was vital for servicemen and workers to be made club” in those days and he organized superb meet- fit as soon as possible and it was during the war ings in many European countries and enlivened that the concept of rehabilitation became widely them with talks on history and music illustrated accepted. Nicoll was then invited to investigate the man- In 1967 he retired from surgical practice, but agement of traumatic paraplegia on behalf of the his energy and enthusiasm were undiminished. Miners’ Welfare Commission, which arranged for Apart from creating a water garden on the site of him to visit centers in North America in 1947. His a demolished mill in Nottinghamshire, he became report was accepted by Aneurin Bevan, then Min- the first director of postgraduate education at ister of Health, although it was not until 1954 that Sheffield. He taught himself to make tape record- the spinal injuries unit was opened at Lodge Moor ings and to copy slides and built up a large library Hospital in Sheffield with Frank Holdsworth, on all aspects of medicine and surgery for the use Nicoll’s close friend and colleague, in charge of of doctors throughout the region. When he gave this up, he turned to editing and Fractures of the spine were common in miners, produced the English edition of a new Italian and Nicoll’s wide experience at Mansfield con- journal, Lo Scalpello, which later became the vinced him that simple wedge fractures were Italian Journal of Orthopedics and Traumatol- stable and needed no treatment, apart from a short ogy. When competent translators became difficult period of rest followed by exercises. This brought to find, he learned to read Italian, although he was him into sharp, but good-humored, conflict with already in his 80s. Watson-Jones, who was adamant that these frac- His outgoing personality, his penetrating tures should be immobilized in a hyperextension approach to orthopedics and his willingness to plaster for 4 months. When Watson-Jones lec- challenge orthodoxy made him welcome all over tured on fractures of the spine, he used to show a the world. He lectured in North America, Brazil, slide of a patient in a plaster cast labeled “Watson- South Africa and in nearly all the countries of Jones’method,” followed by a slide that was com- Europe. The first was of a miner going back to work in the pit, labeled “three months after Nicoll’s treatment”; the second slide was completely blank and labeled “four months after Watson- Jones’ treatment. His reputation grew rapidly and he contributed many important papers to The Journal of Bone and Joint Surgery. Most were on trauma: these included contributions on fractures of the dor- 243 Who’s Who in Orthopedics served all these hospitals until his retirement in 1971. This bare outline of his career does nothing to highlight his special talents or his stimulating per- sonality. In the early years he contributed erudite papers on the pathology of carpal tunnel syn- drome and of Morton’s metatarsalgia, but soon developed his special interest in osteoarthritis of the hip—or “primary coxarthrosis,” as he pre- ferred to call it. Early on, he was quick to embrace the novel technique of replacement of the femoral head pioneered by the Judet brothers of Paris in 1950, and he wrote a book on the subject. The operation, however, failed to pass the test of time and was abandoned. From then on, Nissen championed the cause of minimal displacement intertrochanteric Karl Iversen NISSEN osteotomy of the femur, a development of the original McMurray osteotomy. He saw in this a 1906–1995 means of promoting natural healing through the medium of “tufts” of cartilage that sprouted from Karl Nissen began his career in England only 2 the articular surfaces. In many cases he was years after that great pioneer, Sir Robert Jones, indeed able to show the reappearance of a sub- had died. He was almost contemporary with such stantial cartilage space after the operation, which surgeons as Watson-Jones, Osmond-Clarke and could persist for 20 years or more. He added luster to the orthope- for this “conservative” operation with character- dic scene. Nissen and Charnley each fying in 1932 from the University of Otago, he performed his chosen operation before the first went into general practice before deciding to cameras for a notable television program some 30 specialize. A research project followed, in which years ago: Nissen was always keen to show later he studied in great detail several generations radiographs of his patient, who had gained lasting of a family affected with brachydactyly. In another project he Royal National Orthopedic Hospital he organized studied that ancient reptile, the tuatara—almost and convened annual postgraduate courses for unchanged in 130 million years and unique to young surgeons from European countries. He brought him many lasting friendships among never returned to New Zealand. After a period in European colleagues and led to his being elected general surgery, he trained in orthopedics at the as corresponding member of most of the ortho- newly established Princess Elizabeth Orthopedic pedic societies of Western Europe—honors that Hospital in Exeter, under the tutelage of Norman he greatly cherished.

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The third theme is the transformation of the medical role and the emergence of new institutions that mediate between the individual and the state in the sphere of health order minocin 50 mg line virus examples. The change in the role of the doctor is most apparent in general practice cheap 50 mg minocin shot of antibiotics for sinus infection, in many ways the front line of the advance of medical intervention in lifestyle. In the not-so- distant past, general practice was a demand-led service: patients came to the surgery complaining of illness and doctors offered diagnosis and treatment, care and concern, within the limits of their own abilities and those imposed by medical science and health service resources. Over the past decade, general practice has shifted to a more pro-active approach, inviting patients to attend for health checks and screening procedures and adopting a more interventionist role in relation to lifestyle issues, such as smoking and drinking, diet and exercise. Instead of serving their patients’ needs, GPs now serve the demands of government policy—and the dictates of government-imposed health promotion performance targets. New procedures, such as the routine check-up and the lifestyle questionnaire, allowing the systematic recording (now in a readily accessible computerised form) of intimate knowledge of the patient, have become a familiar feature of the doctor-patient relationship. Having taken on a major role in health promotion, the government has worked with the established organisations of the medical profession—the various royal colleges, the BMA and others—to push forward initiatives like the Health of the Nation campaigns of the early 1990s. It has also recognised the limitations of these traditionally conservative and inflexible bodies and has encouraged the development of a range of institutions to play a more dynamic role. An early example of this approach was the establishment of the Health Education Council in 1968; this was transformed into the Health Education Authority in the heat of the Aids crisis twenty years later and was finally wound up in 2000 as its functions were subsumed by New Labour’s Health Development Agency and other public health initiatives. The internal controversies 68 SCREENING of this body— and its well publicised tensions with government— reflect some of the difficulties involved in developing a novel health promotion approach (Farrant, Russell 1986). The anti-smoking campaign ASH, formed in 1971 with funding from the Department of Health, provided a model for numerous health-oriented voluntary organisations and pressure groups which flourished from the 1980s onwards, popularising health promotion messages. The big Aids charities—notably the Terrence Higgins Trust and the National Aids Trust—both heavily reliant on government funding, played a major role in the safe sex crusade. As we have seen, the big cancer charities have complemented the activities of the national screening agencies in encouraging women to have smears and mammograms. Together with new health organisations and campaigns came a new corps of health professionals, skilled in the techniques appropriate to the advance of health promotion. Some of these were doctors, many more were nurses, only too keen to adapt their traditional skills to the requirements of the new discipline. While campaigning groups oriented towards politicians and the media required organisers, fund-raisers and journalists, those engaging with the public required skills in counselling in general, often combined with more specific expertise, required for example to give advice about diet, sexual behaviour or ‘smoking cessation’. The exercise cult has provided employment for numerous personal trainers, aerobics instructors and others, who are now likely to have received basic health promotion training. The fact that activities once proscribed as sinful—gluttony, sloth, lust—are now regulated in the name of health has led numerous commentators to draw parallels between the ascendancy of health promotion over lifestyle today and the rule of religion in the past. The common features are indeed striking: the devotion to the cause of fitness displayed by the faithful, the spirit of self-denial required to sanctify the body, the zealotry of the newly converted, the dogmatism of the clergy. It appears that health provides some compensation for the decline of traditional religion, both as a focus of individual aspiration and as a secular moral framework for society. The focus of health promotion on lifestyle risk factors for disease emphasises individual responsibility and demands compliance with 69 SCREENING the appropriate medically-sanctioned standard of behaviour as a duty to society. The burden of personal responsibility is reinforced by elevation of risks to others that may arise from individual failings: hence the emphasis on ‘innocent victims’ of HIV/Aids (children, haemophiliacs), the passive smoker, the foetus (of smoking, drinking, drug-taking mothers). Since traditional moral sanctions on behaviours considered deviant have become ineffective as a result of the declining power of the churches in society, values derived from health promotion have acquired growing influence. As the American historian Francis Fukuyama has noted, ‘we feel entitled to criticise another person’s smoking habits, but not his or her religious beliefs or moral behaviour’ (quoted in Thomas 1997). Indeed smokers have become pariahs in modern society—and those who depart from other healthy lifestyle standards (such as the conspicuously obese) can also expect to meet with explicit social disapproval. In this way, the individual’s state of health—as manifested in the state of their body—provides a sphere in which they can be held to account for their personal behaviour. People may no longer confess their sins to the priest in private, but their state of health provides public testimony to their conformity with the new moral code of healthy living, a code which is in many ways more authoritarian and intrusive than the religious framework it has replaced. In expanding to fill the moral vaccuum resulting from the decline of the churches and the increasing fragmentation of society, medicine has come to play a much wider social role.

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Further editing and alterations will be required order 50mg minocin with mastercard antibiotic resistance grants, as almost certainly you will have gone over time purchase 50 mg minocin with amex antibiotic resistance statistics. Some find it a useful ploy at this stage to record the talk on a tape recorder and listen to the result very critically. The next stage is to present the paper to an honest and critical colleague. Most authorities consider that you should be well enough rehearsed to speak only with the aid of cue cards or the cues provided by your visual aids. If you have a highly visual presentation most of the audience will be looking at the screen so the fact that you are reading is less critical. Providing the text is written in conversational style, and you are able to look up from the text at frequent intervals, then reading is not a major sin. The chief risk of speaking without a text in a very short presentation is going over time which at best will irritate the chair and the audience, and at worst will result in your being cut off in mid-sentence. Not only will you receive comments on the presentation but you will also be subject to questions, the answering of which, in a precise manner, is just as important as the talk itself. PREPARING THE ABSTRACT AND YOUR CONTRIBUTION TO THE PROCEEDINGS OF THE CONFERENCE The abstract Most conferences will require you to prepare an abstract, sometimes several months before the meeting. It may initially be used to help select contributions and will ultimately be made available to participants. Contributors are often tardy in preparing their abstracts which is discourteous to the conference organisers and makes their task more difficult. It should outline the background to the study and summarise the supporting data and the main conclusions. Quite frequently abstracts promise what they do not deliver so avoid becoming guilty of false advertising. The proceedings Many national and most major international conferences will publish proceedings. Should you be presenting a paper as such a conference you will be required to provide your contribution to these proceedings during the conference or shortly afterwards. It is not appropriate to present the organisers with the script and slides that you have just used in your presentation. The contribution to the proceedings should be written in a style consistent with that used in a journal article. The content should be the same as in the presented paper but not necessarily identical. It is perfectly permissible to expand some areas, particularly with regard to the methods and results sections, where more details could be included. This should, of course, all be done within the guidelines for format and length specified by the organisers. This saying provides a reminder that, however good your preparation for the presentation of the paper has been, there is still plenty that can happen to ruin your carefully laid plans. You should find it useful to work your way through the checklist in Figure 4. Handling questions Most conferences have a fixed period of time for questions. Some people in the audience are going to test you out with penetrating questions and how you handle them will enhance or detract from the impact of your performance. This is one of the reasons why we suggested a full dress rehearsal in front of your department in order to practice your answering of difficult questions for which some participants will be eagerly searching. The following are some points to remember: Listen to the question very carefully. If the question is complex or if you suspect that not all the audience heard it, restate it clearly and succinctly. Avoid the danger of using the question to give what amounts to a second paper. Be alert to questioners who are deliberately trying to trick you or to use the occasion to display their own knowledge of the subject.

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