Co-Director, University of Chicago Pritzker School of Medicine
Only an epidemiologist could believe that either a middle aged non-drinker sitting at home or a teenager going out on a weekend is going to be influenced by government propaganda advising them of the health benefits of ‘sensible drinking’ arteria bologna 8 marzo purchase 40mg telmisartan overnight delivery. But then only an epidemiologist could believe that data based on ‘self- reported’ levels of alcohol consumption can provide a useful basis for quantitative studies hypertension treatment guidelines buy telmisartan canada. The power of the ideology of health promotion is such that even its critics sometimes fall back on attempts to justify a particular lifestyle choice in terms of health blood pressure urination discount 40 mg telmisartan free shipping. Thus, campaigners against the tyranny of counting units of alcohol in different beverages have seized on associations between moderate levels of alcohol consumption and reduced mortality to bolster their case. As Dalrymple observes, ‘even those who warn against health fanatics forget their own principles when an association emerges that pleases them’ (Dalrymple 1998). Both arguments, based—like most of the epidemiology underlying health promotion—on the confusion of association with causation, are equally irrational. Opponents of the ‘health fanatics’ would be on stronger ground if they pointed out that drinking alcohol in its wonderful diversity of forms is a highly pleasurable activity which has, in general, nothing to do with health. The familiar fact that some people drink an excessive amount of alcohol, causing adverse physical, psychological and social consequences, is strictly irrelevant to the drive to regulate the drinking habits of the entire population in the name of health. Exercise Over the past couple of years I have been able to refer my patients to an ‘Exercise on Prescription’ scheme organised by Hackney Council ‘education and leisure’ services in collaboration with the local health authority (Hackney Education and Leisure 1997). Under this scheme 50 THE REGULATION OF LIFESTYLE I can refer patients to a local leisure centre for a twelve week exercise programme, beginning with ‘a thirty minute consultation with the health and fitness adviser’. They will then ‘be asked to attend at least two sessions a week’ of activities, including ‘low intensity keep fit sessions’, ‘aqua-aerobics and learn-to-swim sessions’, a ‘walking programme’, ‘personal fitness programmes’ and ‘cardiac rehabilitation programmes’. Though the scheme is subsidised, participants are asked to pay between £1 and £2 per session. By 1999 more than 200 such schemes were in operation around the country and were reportedly popular with patients, doctors (and with leisure centres which gained a steady supply of customers during times of low demand). It may seem perverse to criticise a campaign to encourage people to take more exercise, something that many would regard as self- evidently beneficial. Yet it is important to note the subtly coercive character of these exercise programmes. As a doctor, I do not advise or recommend exercise, but I prescribe it, in the same manner as I would a drug or other medical treatment. As the programme leaflet indicates, ‘an exercise prescription is similar to a prescription for medicine issued by your GP…in many cases exercise can help to control certain medical conditions and in some cases reduce the need for medication’. The deliberate use of the term ‘prescription’ implies an expectation that the patient will follow the doctor’s instructions to turn up at the gym, just as they would be expected to take a traditional prescription to the pharmacy and take the medication in the manner prescribed: ‘all patients should be made aware of the fact that the prescription is an important part of their treatment’. Issuing a prescripton to take exercise clearly imposes a much greater pressure for compliance on the patient than there would be if the doctor merely advised exercise. In the past, they have often warned of the dangers of particular sports and have complained about the burden on accident and emergency and orthopaedic departments resulting from sports injuries. In 1990 the BMA published a detailed account of the dangers of sporting and leisure activities, noting 155 fatalities in 1987, including some 61 drownings in various water sports, 24 deaths from parachuting, hang-gliding and other forms of aerial recreation, 12 from horse-riding and jumping (though only one in boxing, the target of a continuing medical campaign) (BMA 1990: 147–8). The growing popularity of more dangerous sports, like mountain climbing and off-piste skiing, has led to an increase in sport-related mortality, despite the increasing preoccupation with safety. Two factors have converged to make exercise a key feature of the modern health promotion agenda. One is the burgeoning cult of the body that has become a central theme of Western society over the past twenty years. This began with the vogue for jogging and marathon running in the 1970s and 1980s and has flourished in the form of gym-based fitness training in the 1990s. People seem to have forgotten that Pheidippides, the runner of the first marathon in 490 BC, collapsed and died on reaching Athens—and that James Fixx, who popularised jogging in the USA with his 1977 best-seller, dropped dead on the track in 1984 at the age of 52 (Skrabanek 1994:74–5). The second factor is the increasing medical promotion of the preventive value of exercise in relation to a wide range of health problems, from coronary heart disease and osteoporosis, to depression and anxiety.
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A cut is made, either inside the mouth or outside under the chin. A pocket is created in front of the chin bone and under the muscles. The implant is placed inside.
Pulmonary problems (shortness of breath, air pockets in bloodstream)
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Head imaging study (such as an MRI or CT scan)
Have chest, neck, or shoulder pain
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The other risk factor that we should further con- sider is preoperative collapse blood pressure nausea purchase telmisartan online now, which affects JOA score and survival rate blood pressure check cheap 40mg telmisartan overnight delivery. Once collapse occurs prehypertension examples order telmisartan 40mg line, the vascularized iliac bone cannot support the destroyed bone structure in the femoral head. Male sex and abuse of alcohol were also found to be risk factors for survival rate after VIBG. This finding might be explained by the fact that most osteo- necrosis-affected patients with abuse of alcohol are men. Vascularized Iliac Bone Graft for Femoral Head Necrosis 133 Taken together, VIBG should be indicated in limited cases with early-stage ION. However, we found that patients with pain in the affected hip always showed a certain degree of collapse of the femoral head. In addi- tion, VIBG cannot always prevent progress of femoral head collapse or advancement of osteoarthritic changes, even though the femoral head shows no collapse. We con- clude that VIBG for ION should be indicated for (1) joints without or with little col- lapse of the femoral head and (2) joints with a wide lesion for which transtrochanteric rotational osteotomies are never indicated. VIBG is a time-saving surgery for young patients to postpone total hip arthroplasty or hemiarthroplasty. VIBG cannot always prevent stage progression of the femoral head after ION. Preoperative collapse, sex, total curettage of the necrotic lesion for bone grafts, and bilateral ION reduce JOA score after VIBG. Total curettage of the necrotic lesion, operative age over 30 years, precollapse, and abuse of alcohol reduce survival rate of ION when the endpoint is set at progress of femoral head collapse. VIBG is a “time-saving surgery” for young patients with ION to postpone perfor- mance of total hip arthroplasty or hemiarthroplasty. Solonen KA, Rindell K, Paavilainen T (1990) Vascularized pedicled bone graft into the femoral head: treatment of aseptic necrosis of the femoral head. Cheung HS, Stewart IE, Ho KC, Leung PC, Metreweli C (1993) Vascularized iliac crest grafts: evaluation of viability status with marrow scintigraphy. Sugano N, Atsumi T, Ohzono K, Kubo T, Hotokebuchi T, Takaoka K (2003) The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. Hasegawa Y, Iwata H, Mizuno M, Genda E, Sato S, Miura T (1992) The natural course of osteoarthritis of the hip due to subluxation or acetabular dysplasia. Pavlovcic V, Dolinar D, Arnez Z (1999) Femoral head necrosis treated with vascular- ized iliac crest graft. Eisenschenk A, Lautenbach M, Schwetlick G, Weber U (2001) Treatment of femoral head necrosis with vascularized iliac crest transplants. Feng CK, Yu JK, Chang MC, Chen TH, Lo WH (1998) Vascularized iliac bone graft for treating avascular necrosis of the femoral head. Nagoya S, Nagao M, Takada J, Kuwabara H, Wada T, Kukita Y, Yamashita T (2004) Predictive factors for vascularized iliac bone graft for nontraumatic osteonecrosis of the femoral head. Hasegawa Y, Iwata H, Torii S, Iwase T, Kawamoto K, Iwasada S (1997) Vascularized pedicle bone-grafting for nontraumatic avascular necrosis of the femoral head. Norman D, Reis D, Zinman C, Misselevich I, Boss JH (1998) Vascular deprivation- induced necrosis of the femoral head of the rat.
Trial and selection of electrically powered equipment includes telephone blood pressure chart related to age buy telmisartan without prescription, computer and assessment of environmental control systems heart attack x factor cheap 20 mg telmisartan visa, which can enable the individual to operate via a switch a range of functions blood pressure medication generic purchase telmisartan 80mg without a prescription, including television, video, intercom, computer, lights, radio, and accessing the telephone. In incomplete spinal cord lesions, where there can be use variable potential for neurological recovery, it may not be possible to • May be able to assist with transfer from wheelchair onto level predict functional outcome, which can lead to increased anxiety for the surfaces using a sliding board and an assistant patient. Complete lesion below C6: As the adult with a spinal cord lesion becomes older their ability to • Able to extend wrists maintain their level of independence may diminish and require review. As soon as is practicable liaison occurs between the spinal centre staff, the patient and the patient’s local district wheelchair service. They are able to assess and provide wheelchairs from a range, which includes self-propelling, lightweight, indoor powered, indoor/outdoor powered and Figure 10. The occupational therapist should be able to guide the individual to trial and select a wheelchair with features that suit the patient’s functional ability and lifestyle. An extensive range of wheelchairs is available commercially, including those that tilt in space and enable standing, and outdoor powered wheelchairs. Driving and vehicles Several centres specialise in assessing an individual prior to returning to driving and give advice on the trial and selection of controls that suit an individual’s functional ability. The assessment also includes advice on methods of storage of the Figure 10. For individuals who wish to remain in their wheelchair whilst travelling, either as a driver or a passenger, the choice of wheelchair must be matched with the choice of vehicle and the individual’s size. Leisure Constructive use of leisure time is vital to maintain self-esteem and self-confidence. Some previous activities and interests can be continued, with a little thought and suitable adjustment. There are many national groups and organisations with facilities to support individuals to pursue their hobbies, sporting interests, travel and holidays, and access to the internet has widened the range of information available. Work consider some alternative employment they can contact their local employment service, which may be able to offer practical Work is of varying importance to patients, but some will see it advice and financial support. Early contact with employer, school, or college, the occupational therapist is able the patient’s employer to discuss the feasibility of eventual to assess the suitability of the premises for wheelchair return to his or her previous job is important. If the degree of a accessibility and make recommendations on the facilities which patient’s disability precludes this, some employers are would be necessary. The advance of information technology sympathetic and flexible and will offer a job that will be has increased employment opportunities for patients of all possible from a wheelchair. As a result of their spinal cord injury, some people use the opportunity to take stock of their lives and retrain or enter further education. Some people choose not to return to paid Further reading employment but seek occupation in the voluntary sector. Many patients find life outside hospital difficult enough initially, • Curtin M. Development of a tetraplegic hand assessment however, without the added responsibility of a job, and in these and splinting protocol. Paraplegia 1994;32:159–69 circumstances a period of adjustment at home is advisable • Whalley Hammell K. When such patients feel ready to London: Chapman and Hall 1995 56 11 Social needs of patient and family Julia Ingram, David Grundy The aim of successful rehabilitation is to enable the patient to live as satisfactory and fulfilling a life as possible. This will mean different choices and decisions for each individual depending on the degree of disability, the family and social environment, and preferred lifestyle. The vast majority of patients want to live in their own homes and not in residential care, and very severely disabled Table 11. Many will live as part of a injury discharges from The Duke of Cornwall Spinal Treatment family or, increasingly, choose to live independently with Centre 1998–99 support from community services. Caring for People (Cm 849, Where patients are living % 1989) recognised this, and in April 1993 the legislation was enacted, facilitating provision of care in the community, and Living with relatives after discharge 29 for the first time the needs of carers were specifically Living independently or with partner on discharge 57 mentioned.
The public want a higher standard of care but what they may get is the opposite blood pressure variations cheap 20 mg telmisartan visa. Doctors want better training but what we are cur- rently getting is the opposite prehypertension american heart association discount 40 mg telmisartan fast delivery. The removal of the PRHO is yet another step in mod- ernising training and many junior and senior doctors have grave reservations about the new Foundation Scheme blood pressure form buy discount telmisartan 40 mg on-line. However, not everything about modernising medical careers (MMC) is bad and certainly the quality of life Foundation Trainees will have is far greater than their predecessors. Certain parts of the Foundation syllabus are to be commended and the overall doctor which it is trying to create is one who has an overall understanding of patient centred care, good communication, and a keen eye to spot a sick patient and prevent clinical incidents. I agree that this can only be a good thing but at what expense – knowledge and experience? Foundation Schemes The Foundation Scheme is a two-year programme divided into an F1 year (year 1 which is approximately equivalent to current PRHO training) and an F2 year (which is equated to year 1 of an SHO). The Foundation programme has been designed to produce ‘demonstrably com- petent doctors who are skilled at communicating and working as effective members of a team’. When I was at medical school it was the task of the interview panel to decide whether you were skilled in the latter two. I should state that I do not think that those exiting the Foundation Scheme will be as poorly trained as some of my senior colleagues fear. However, despite major concerns regarding purely ‘academic’ teaching, there are aspects of the Foundation Programme which deserve credit. The core areas of assessment are outlined in the Curriculum for the foundation years in postgraduate education and training. The Response of the 4 UK Health Ministers to the Consultation on Unfinished Business: proposals for the reform of the SHO grade. Applying for Pre-registration House Officer Posts 7 areas: knowledge, attitudes and skills. The F1 year will consist of three four-month posts in medicine, surgery and one other specialty. The F2 year is split into three four-month placements including acci- dent and emergency (A&E) followed by two blocks of either surgical or medical spe- cialities. Alternatively the year is split into four three-month placements and this depends on which area of the country you apply to . Other specialties may be taken in addition to medicine and surgery, but these have not been finalised. However, these are reported to include A&E, critical care, general practice, obstetrics and gynaecol- ogy, paediatrics, pathology and psychiatry. It is thought (or hoped) that a scheme will be finalised by 2006, but until then we will have to rely on our imagination (Figure 3. My advice would be to clerk, examine, investigate and treat as many patients as you possible can in the short training that you will have as this will be the only pos- sible way of gaining experience. I do not wish for you to finish reading this chapter and think that your training will be poor or that I am against change. Far from it, I think that your training will be different and none of us (including you) have any idea just what tomorrow’s doctors will be like.
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