Assistant Professor, University of Nebraska College of Medicine
The ataxia with cytarabine is most often seen when the drug is 2 administered in high dosage menstrual like cramps at 33 weeks generic 60 mg evista amex, e menstrual hygiene management buy cheap evista online. Cytarabine injures Purkinje cells and the ataxia typically but not always resolves spontaneously menstruation normal cycle buy evista in india. Although this chemother- apeutic is key in the treatment of AML, whether a child whose ataxia resolves should be re-challenged with this drug is unclear. While paraneoplastic syndromes are rare in children, opsoclonus-myoclonus associated with ataxia in a toddler can be the harbinger of thoracic or abdominal neuroblastoma. As opsoclonus-myoclonus is an autoimmune reaction associated with humoral response to neuroblastoma, the syndrome often resolves with just therapy of the tumor. In some instances, the autoimmune response can cause 262 Fisher more extensive or persistent neurologic damage. Isolated reports have described improvements to persistent neuroblastoma-associated opsoclonus-myoclonus with use of prednisone, ACTH, or intravenous immunoglobulin. NEUROPATHY Neuropathy, in general, is rare in children but in the oncology setting seen most often with vincristine or cisplatin. With vincristine, the neuropathy is a length- dependent, small-fiber axonal neuropathy. Pathologic examination of nerves shows axonal degeneration with regeneration affecting both myelinated and unmyelinated axons. Foot and toe dorsiflexion and foot everters are initially affected, with loss of ankle jerks. The associated weakness is reversible, with recovery taking months after drug discontinuation, although some patients have persistent minor residual deficits. It is usually best to ‘‘dose through’’ rather than reduce vincristine in the presence of neuropathy while employing ankle–foot orthoses and physical therapy, unless the neuropathy threa- tens walking. Cranial neuropathies (often unilateral rather than bilateral) are less common, but may result in jaw pain or facial weakness upon infusion early in treat- ment. Vincristine must be avoided in children with Charcot–Marie–Tooth disease, in which there is risk of irre- versible paralysis with administration of the drug. It is essential that the clinician inquire about a family history of this disease, pes cavus, or neuropathy before administering this drug. Children will show depression of vibratory sensa- tion and loss or proprioception, sometimes with refusal to walk or bear weight. Muscle cramps occur more commonly with cisplatin neuropathy than vincristine neuropathy. This high-frequency hearing loss is irreversible and progresses with increased cumulative dosage. Prior radiotherapy may enhance damage, as the radiotherapy can cause an obliterative cochlear arteritis. Other agents associated with neuropathy in the setting of childhood cancer are listed in Table 6. Table 6 Chemotherapeutics Associated with Neuropathy Carboplatin Cisplatin Cytarabine (rare) Doxorubicin (rare) Etoposide Paclitaxel Procarbazine Teniposide Thalidomide Vinblastine Vincristine Neurologic Effects of Cancer 263 MYOPATHY In the oncology setting, myopathy is noted commonly with the prolonged adminis- tration of dexamethasone in patients with brain tumors or prednisone or other ster- oids in children with other malignancies. Steroid myopathy is treated by discontinuation of the drug, if possible, after which, the myopathy usually resolves over months. Chemotherapeutics associated with myopathy include 5-azacytidine, doxorubicin, and paclitaxel. INTRODUCTION According to data from the Central Brain Tumor Registry of the United States (CBTRUS), the incidence of childhood brain tumors is 3. It is estimated that there are 26,000 children diagnosed with a primary brain tumor living in the United States, and over 3000 children are diagnosed with a primary brain tumor every year.
I see many young people menstruation cycle calendar buy generic evista 60mg on-line, usually in professional occupations women's health northeast evista 60mg free shipping, who worry about their health women's health center kirkland wa discount 60mg evista amex, watch their diet and take regular exercise. They also seek regular check-ups and screening tests for various diseases. I also see many old people, often former manual workers, who have never been much concerned about their health and have rarely modified their lifestyles or consulted their doctors with a view to preserving it. If you congratulate them on their longevity, they often say that they only wish they had not lived so long. Sometimes they even request my help in assisting their escape from the misery of loneliness, infirmity and poverty. To the former, government health campaigns are a welcome response to a heightened sense of individual vulnerability to environmental dangers. The popular resonance for appeals for greater health awareness reflects the anxieties and insecurities that particularly afflict the younger and more prosperous sections of society. To an older and less affluent generation, these campaigns simply confirm the shift of the health service, as well as other institutions in society, away from any real concern for their needs. The positive response to official public health documents, such as Saving Lives and earlier health promotion initiatives, from the medical profession and the media in general, indicates the widespread acceptance of the basic assumptions of these programmes. But, aside from the specific proposals, some questions arise concerning the underlying principles. We can begin by noting a striking paradox: at a time when, by any objective criterion, people enjoy better health than at any time in human history, the government appears driven to ever greater levels of intervention to improve people’s health. Take life expectancy: the commitment to increase it is the first of the ‘aims’ proclaimed by the White Paper. But why should this be the ultimate target of medical science, let alone of government policy, least of all at a time when the increasing longevity of the population has become a widely acknowledged social problem? A boy born in Britain today can expect to live until he is nearly 75; a girl until over 80. Life expectancy has increased by more than 30 years over the past century and by around a decade since the Second World War, apparently without the benefit of government-sanctioned measures of health improvement. It is clear that we have not only exceeded the 2 INTRODUCTION biblical lifespan of ‘three score and ten’ but that more and more of us are reaching closer and closer to the biological limit of the human species. There is much scientific debate about whether further increase in life expectancy is possible. 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. The controversy over euthanasia and the romanticisation of suicide among young men (such as rock stars Kurt Cobain and Michael Hutchence) reflect a deeply pessimistic current in contemporary society. The desire simply to live longer by taking health precautions may be interpreted as another way of responding to the perception that life in modern society lacks meaning and purpose. The promoters of health awareness will object that their emphasis is not so much on ensuring that people live longer as on preventing premature deaths. They will point out that, even though there is an average life expectancy of 75– 80, more than 90,000 people die every year in the UK before the age of 65. Furthermore, some 32,000 of these deaths are from cancer and 25,000 from heart disease and strokes, many of which could have been prevented. In this context, the concept of prevention is abused: death cannot be prevented, only postponed. Unfortunately, given the current state of medical science, death can generally be postponed only for a relatively short time by relatively intensive preventive measures. In the nineteenth century, public health measures to improve sanitation and housing played a decisive role in curtailing the epidemics of infectious diseases that devastated the urban poor. Over the past two decades, proponents of the ‘new public health’ have emphasised the promotion of a healthy lifestyle as the key strategy to combat the modern epidemics of heart disease and cancer.
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Admittedly women's health clinic indooroopilly purchase generic evista line, people don’t want to “burden” their spouse pregnancy costumes purchase evista 60mg on line, partner breast cancer vaccine cleveland clinic order evista 60 mg visa, or children. Nevertheless, they also don’t want to leave home, to be institutionalized. Among people with minor mobility problems, 60 percent get help only from their spouse, parents, or children, as do 48 percent with moderate and 38 percent with major difficulties. The vast majority of “informal caregivers”—relatives, friends, and neighbors who provide unpaid assistance (Kleinman 1988; Kane, Kane, and Ladd 1998; Roszak 1998; Pipher 1999; Stone 2000; Levine 2000)—are fe- male family, primarily wives or daughters. However, people with mobility problems are more likely to live alone than others: 10 percent of people without mobility difficulties compared to 16 percent of those with minor and moderate and 14 percent of those with major difficulties. Not surprisingly, therefore, increasing mobility difficulties are associated with suggestions of social isolation (Table 8). While 70 percent of people with minor difficulties got together with friends during the preceding two weeks, only 55 percent of persons with major problems did. Rates of seeing relatives, talking on the telephone with friends, and attending various activ- ities are lower in people with major versus minor mobility difficulties. Al- most 49 percent of people reporting major mobility difficulties want more social contacts compared to 31 percent of those with minor problems. Within families, giving and receiving such help blurs the boundaries delin- eating independence from dependence, privacy from exposure, and being in or out of control. When partners begin performing routine tasks, “this can create inequity, conflict, blame, guilt, dependence, resentment”—a re- balancing becomes necessary (Olkin 1999, 117). Social Encounters in the Last Two Weeks Social Encounter (%) Mobility Visited Ate Attended Church Difficulty Friends Out or Temple Mild 70 60 46 Moderate 62 52 39 Major 55 44 30 terviews illustrate these diverse dynamics. The first finds Joe DiNatale cradling his wife, Tina, in his arms, carrying her to the basement bathroom of a North End restaurant, to surfside at the seashore, up the two steps of their garage entryway. Joe has the power literally to sweep her off her feet, despite Tina’s protestations that she’d rather walk, albeit slowly. The second shows Gerald Bernadine recognizing that his MS not only partially redefines his sense of self but also shapes his interactions with others. And so, when I got MS, I finally just had to accept that I was ill; I had to accept limi- tations; I had to accept a helping hand from people. One thing that I’ve learned is that, when somebody reaches out to help you—even if you can help yourself, even if you don’t need that help—it’s really nice to accept it. The third is Walter Masterson’s pained recognition of his progressive debility and the “proper role” for his wife, Nancy: We are beginning to think about and verbalize some of the things that will be problems. So that means that what you see before you, in a slightly reduced form, will have to be manhandled for various things. During the early moments of the interview, before his powerful Parkin- son’s disease medications precipitated their characteristic writhing dyski- At Home—with Family and Friends / 93 nesias (abnormal body movements), Mr. We didn’t know how much to let him be who he had to be and struggle to get around. But at the same time, we knew there were easier ways—just by us helping him or by getting a wheelchair. The psychotherapist Olkin (1999, 116) warns, “When disability joins a couple, predisability marital issues will be reflected and accentuated.
X The term ‘triangulation’ is used when a combination of qualitative and quantitative forms of inquiry are used womens health kc order evista australia. FURTHER READING The theoretical and philosophical issues raised in this chapter are detailed and complex and cannot be discussed in depth in this book women's health clinic unionville evista 60 mg without a prescription. However menstrual odor symptoms buy 60 mg evista, if you wish to pursue any of these topics, some of the useful publications are listed below under the relevant topics. Qualitative research Over recent years there has been a great deal of innova- tion in the use of qualitative methodologies. Listed below are some of the more traditional texts and a selection of the newer, innovative texts. Before you de- cide which would be the most appropriate methods for your research, you need to find out a little more about these tools. This chapter gives a description of the meth- ods of interviewing, focus groups, questionnaires and par- ticipant observation. Chapters 7–10 will go on to describe in detail how to use each of these methods. The most common of these are unstructured, semi-structured and structured interviews. If you want to find out about other types of interview, relevant references are given at the end of this chapter. Unstructured interviews Unstructured or in-depth interviews are sometimes called life history interviews. This is because they are the fa- voured approach for life history research. In this type of interview, the researcher attempts to achieve a holistic un- derstanding of the interviewees’ point of view or situation. For example, if you want to find out about a Polish man’s experiences of a concentration camp during the war, 27 28 / PRACTICAL RESEARCH METHODS you’re delving into his life history. Because you are unsure of what has happened in his life, you want to enable him to talk freely and ask as few questions as possible. It is for this reason that this type of interview is called unstruc- tured – the participant is free to talk about what he or she deems important, with little directional influence from the researcher. As the researcher tries to ask as few questions as possible, people often assume that this type of interviewing is the easiest. Re- searchers have to be able to establish rapport with the par- ticipant – they have to be trusted if someone is to reveal intimate life information. Also, some people find it very difficult to remain quiet while another person talks, sometimes for hours on end. Researchers need to remain alert, recognising important information and probing for more detail. They need to know how to tactfully steer someone back from totally irrelevant digressions. Also, it is important to realise that unstructured interviewing can produce a great deal of data which can be difficult to analyse. Semi-structured interviews Semi-structured interviewing is perhaps the most com- mon type of interview used in qualitative social research. In this type of interview, the researcher wants to know specific information which can be compared and con- trasted with information gained in other interviews. To do this, the same questions need to be asked in each inter- HOW TO CHOOSE YOUR RESEARCH METHODS / 29 view. However, the researcher also wants the interview to remain flexible so that other important information can still arise. For this type of interview, the researcher produces an in- terview schedule (see Chapter 7).
Sharpey was both friend and At the proper time Lister qualified with the MB teacher to Lister and it was he who commended (London) and was appointed house physician and him to Syme menopause bleeding symptoms generic 60mg evista with mastercard. In 1852 he gained the FRCS Inspired by these two men ucsf women's health center mt zion cheap evista 60 mg with amex, Lister women's health questions pregnancy symptoms generic evista 60 mg otc, while yet an (England) and the next year went to Edinburgh undergraduate, carried out original work on the with an introduction to Syme. Kölliker surgeon received him cordially and there began a had discovered that the iris consisted of involun- friendship between them that the years increased. This particular work became his house surgeon, reported his lectures attracted considerable attention and led to a firm to the Lancet, and was a most enthusiastic pupil, friendship between the two observers that lasted eventually marrying his eldest daughter Agnes. After a period assisting Syme in hospital and It was at this time too that anesthesia was intro- private practice, Lister was elected, on October duced into surgical practice. Sir Humphry Davy 13, 1856, to the post of assistant surgeon to the had worked on nitrous oxide in his laboratory, and Edinburgh Royal Infirmary. He held this post for from the narcotic effect of the vapor upon his own 4 years, during which time he lectured on surgery; person declared as early as 1800 that the gas his teaching of which was suffused with pathol- might have its uses in surgery; and in 1824, Henry ogy, for he held that students should have their Hickman of Ludlow proved its efficacy in opera- knowledge built upon, and their reasoning stimu- tions upon small animals. At the same time in America used the gas successfully in his he continued his researches, the fruit of which private practice as a dental surgeon, but when was embodied in papers read before the Royal he attempted to demonstrate its use in general Society. He gained a reputation as a first-rate surgery, he failed dismally and had to face piti- investigator, a stimulating teacher, and a good 198 Who’s Who in Orthopedics operator, added to which he was transparently the beginning of the inflammatory process. He was soon lecturing to one of cated to the Royal Society in 1857 in a paper enti- the largest classes of medical students in Britain, tled “The Early Stages of Inflammation”. This but what impressed him most were the limitations particular study led him to regard putrefaction as of surgery as a means of relief for human suffer- the cause of suppuration and wound infection; ing; gangrene and suppuration were only too rife decomposition was set up, though inexplicably, in hospital wards. Such had been his teaching to students the state of affairs that prevailed. In the case of a when, in 1865, he became acquainted with the compound fracture, the scales were weighted on writings of Pasteur, and learned that putrefaction the side of the loss of life or limb. Hospital gan- was a fermentation due to the growth of minute grene is to us a term in medical history, but to our microscopical organisms, which were dissemi- predecessors it was a perpetual black menace. This of inflammation and suppuration in wounds and was an astounding revelation; it was the opening looked upon them as a natural and inevitable of a biological new world of microorganisms. But Lister, pained and Lister soon realized that Pasteur’s explanation distressed by the frustration of surgery, was of putrefaction was applicable to the decomposi- unwilling to accept this fatalistic attitude and tion of wounds. Already he had thought the air to regarded “hospital diseases” as an evil to be over- be a contaminating influence, and this view was come. More and more did his thoughts turn to now confirmed and the active agent revealed. His ideal of what next step was to prevent microorganisms from should happen in a wound was what occurred in gaining access to the open flesh. To the attainment a subcutaneous injury, such as a simple fracture of this ideal, and to the perfection of its accom- in which repair took place without inflammation, plishment, Lister dedicated the rest of his life. He suppuration, or constitutional disease; and none started by casting about for a suitable antiseptic was better placed or better equipped for the solu- and on learning of the success of carbolic acid as tion of this baffling problem. From early life he a disinfectant in dealing with sewage at Carlisle, had been accustomed to the scientific attitude he decided to give this chemical a trial on wound towards phenomena around him and he had been treatment. After investigation with the pure acid, fortunate in the masters who trained him. When he finally adopted a 1 in 20 watery solution, and he arrived in Glasgow, he was already mature as this strength of carbolic acid became a permanent a scientific investigator; indeed among surgeons feature of his technique.
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