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By V. Taklar. Saint Cloud State University.

Even though the government has allocated more funds to the health service purchase 100mcg proventil fast delivery, its wider policies are imposing a burden of expectations that will be almost impossible to fulfil proventil 100 mcg discount, but will have far reaching consequences for our ability to live our lives as we choose purchase proventil 100 mcg with visa. It had a profound effect on society and accelerated changes in the relationships between the state and the individual purchase proventil 100mcg line, and between doctor and patient generic proventil 100 mcg with mastercard, that had been proceeding more gradually over the previous decade. A phenomenon of much wider significance than the novel viral infection on which it was based, the panic was both a product of the peculiar insecurities of the historical moment in which it emerged and a force which intensified them. While the panic provoked private fears of a deadly disease, it also fostered new institutions embodying new forms of solidarity and promoted, in the form of the safe sex code, a new moral framework. It encouraged an already growing preoccupation with health or, to be more precise, with disease. The contemporary obsession with illness and death, with morbidity and mortality, so powerfully reinforced by the Aids crisis, increased the dependence of patient on doctor and strengthened the authority of the state over the individual. My first encounter with the Aids scare followed the death of Rock Hudson in 1985, before the panic had really taken off. This former matinee idol had died soon after the devastating impact of Aids had led to the public confirmation of both the nature of his illness and his homosexuality. A middle aged woman—a former fan, who had closely followed the news-story—went into a panic attack when she realised that she had shared a coffee cup with a gay man at work and came rushing in to the surgery. I heard several similar stories after the panic proper took off towards the end of 1986, and then again after the death of pop singer Freddie Mercury in 1992, and again with each upswing in the level of popular anxiety. I remember a teenage boy who came in following a series of television programmes designed to boost public awareness. Despite his 13 HEALTH SCARES AND MORAL PANICS negligible sexual experience, he was worried he had developed Kaposi’s sarcoma, a once-rare skin cancer that now appears in some people with Aids. He reckoned that the red patch on his chest looked exactly like the one exhibited in the cause of public health promotion, by an Aids patient on television. I remember too a man in late middle age who was terrified that he might have acquired HIV in the course of a single homosexual experience while in the services during the Second World War. The ‘worried well’ became a recognised disease category, their anxieties accepted as a price worth paying for heightened Aids awareness. The Aids panic provided the model for numerous subsequent scares, none reaching the same dimensions, but several making a substantial and enduring impact. Many more minor scares came and went, cumulatively fostering a climate of increasing public anxiety about threats to health that was receptive to a growing scale of state and medical intervention in the personal life of the individual. Alarmed by these scares, people consulted their doctors, not so much because their concern about some particular symptom, but because of their re-interpretation of the significance of this symptom in the light of their new awareness of some wider threat to health. There was (almost) always a rational element in their concern: there was a real threat to health (to some people) at the root of most of the major scares and many of the minor ones. The dominant— irrational—element was expressed in a level of concern that was out of all proportion to the real danger. Let’s look at some of the major and minor health scares of the past decade. Major health scares HIV|Aids In November 1986 the British government launched the ‘biggest public health campaign in history’ about the threat of the Acquired Immune Deficiency Syndrome (Aids) resulting from the Human Immunodeficiency Virus (HIV). Advertisements ominously featuring ‘tombstones’ and ‘icebergs’ appeared on television, in cinemas, on high street hoardings and in the press; the ‘Don’t Die of Ignorance’ household leaflet followed in early 1987. The central theme of this campaign was the risk of a major epidemic of HIV disease in Britain resulting from heterosexual transmission. The 14 HEALTH SCARES AND MORAL PANICS promotion of ‘safe sex’ justified by the risk of Aids became the central theme of a barrage of propaganda through the 1990s, with National Aids Day becoming an annual event marked by the wearing of a red ribbon of Aids awareness. In February 1987 I wrote that there was ‘no good evidence that Aids is likely to spread rapidly among heterosexuals in the West’, a judgement that has been fully vindicated by subsequent developments (Fitzpatrick, Milligan 1987:8). In 1988 a government working party of top epidemiologists and statisticians predicted that, by 1992, Aids cases would be running at around 3,600 a year, though the press seized on its more alarmist projections that the number of cases could reach 12,000 (DoH 1988). By the end of 1999, some 15 years after the beginning of the epidemic in Britain, the total number of Aids cases had reached around 17,000 (PHLS March 2000). More than two- thirds of these cases were among gay men (who had accounted for almost 90 per cent of cases in the late 1980s). The number of cases spread by drug abusers sharing needles was around 1,000 (a number that had grown much more slowly in the late 1990s). There had been a substantial growth in cases acquired by heterosexual transmission, up to around 3,000, but 2,500 of these had become infected abroad (2,000 in Africa). Of the remainder, less than 300 had become infected through contact with somebody in a recognised high risk group (bisexual/drug user).

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Theory and Indication of Manipulative Reduction The case that is classified as acute/acute on chronic type purchase proventil 100 mcg online, clinically classified as un- stable type by Loder et al order 100mcg proventil mastercard. The manual reduction technique that we use for the hip with physeal instability is not a forceful manipulation purchase proventil 100mcg fast delivery, but rather a quiet and gradual flexion order proventil 100 mcg online, abduction proventil 100 mcg line, and a Fig. Note that only the acute portion of the slippage was reduced, and overreduction was avoided 6 H. Also, it is important to reduce only the acute portion of the slippage and not to overreduce. Morphological improvement gained by manual reduction would lead to functional improvement of the hip and lower the risk of arthritis in the future. Although the possibility is undeniable that blood circulation in the femoral head may be compro- mised, the opposite possibility does exist, that is to say, manual reduction could improve blood circulation, as indicated by Kita et al. Taking these considerations into account, we believe our treatment policy is well justified. Their reports recommended early reduction for unstable SCFE, which was proved by good clinical results. Dynamic Single-Screw Fixation Chronic/stable type slippage with PTA less than 40° is treated by in situ fixation. In the past, we used multiple devices for internal fixation; however, we have been using single-screw fixation recently, which is reported to have a lower complication rate than fixation with multiple screws. A 5-year-old girl and a 12-year-old boy were treated with this dynamic method and are presently being followed (Fig. For the former patient, several screw replace- ments are anticipated before physeal closure occurs. Dynamic single-screw fixation was used Surgical Treatment for SCFE 7 Osteotomy Chronic/stable type with PTA of 40° and more has been treated by trochanteric and subcapital osteotomy. We employed the Southwick procedure in the past for the chronic/stable type with PTA of 40° to 70°. This procedure is relatively technically demanding, yet does not always seem to be successful in achieving the intended correction. Thus, we are now trying to understand the pathology using computed tomography (CT) scan for accuracy, and also to consider simple flexion osteotomy, depending on the situation (Fig. Lalaji A, Umans H, Schneider R, et al (2001) MRI features of confirmed “pre-slip” capital femoral epiphysis: a report of two cases. Otani T, Suzuki H, Kato A, et al (2004) Clinical results of closed manipulative reduc- tion for acute-unstable slipped capital femoral epiphysis. Bellemans J, Farby G, Molenaers G, et al (1996) Slipped capital femoral epiphysis: a long-term follow-up, with special emphasis on the capacities for remodeling. Loder RT, et al (1993) Acute slipped capital femoral epiphysis: the importance of physeal stability. Aronsson DD, Lorder RT, et al (1996) Treatment of the unstable (acute) slipped capital femoral epiphysis. Casey BH, Hamilton HW, Bobechko WP (1972) Reduction of acutely slipped upper femoral epiphysis. Kita A, Morito N, Maeda S, et al (1995) Indication and procedure of manual reduction and subcapital osteotomy for slipped capital femoral epiphysis. Peterson MD, Weiner DS, Green NE, et al (1997) Acute slipped capital femoral epiphy- sis: the value and safety of urgent manipulative reduction. Gordon JE, Abrahams MS, Dobbs MB, et al (2002) Early reduction, arthrotomy, and cannulated screw fixation in unstable slipped capital femoral epiphysis treatment. Kumm DA, Lee SH, Hackenbroch MH, et al (2001) Slipped capital femoral epiphysis: a prospective study of dynamic screw fixation. Kamegaya M, Saisu T, Ochiai N, et al (2005) Preoperative assessment for intertrochan- teric femoral osteotomies in severe chronic slipped capital femoral epiphysis using computed tomography. J Pediatr Orthop B 14:71–78 Treatment of Slipped Capital Femoral Epiphysis Motoaki Katano, Naonobu Takahira, Sumitaka Takasaki, Katsufumi Uchiyama, and Moritoshi Itoman Summary. Slipped capital femoral epiphysis (SCFE) is a comparatively rare disorder with various new treatment modalities. Among unilateral SCFE patients, there were 7 acute, 6 acute on chronic, and 16 chronic SCFE. Pinning was performed on 11, osteotomy on 9, and in situ pinning on 9 hips. Postoperative complications of avascular necrosis of the femoral head were noted in 7 hips (24. For acute SCFE, we perform gentle reduction by traction and epiphysiodesis.

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His textbook Surgical After the war generic proventil 100 mcg with mastercard, during the period when the great Approaches to the Neck cheap 100 mcg proventil mastercard, Cervical Spine cheap 100 mcg proventil free shipping, and famine swept the Ukraine buy proventil 100 mcg mastercard, Dr purchase 100 mcg proventil mastercard. He organized one of the earli- spoke five languages fluently—and his medical est hand-surgery teaching services and clinics in talent brought his work to the attention of Herbert New York City at the Hospital for Joint Diseases. Hoover, who encouraged him to come to the He taught anatomy at the Columbia University United States. He immigrated in 1924 and estab- College of Physicians and Surgeons for more than lished a private practice in New York in 1927. Many contemporary hand surgeons were his students, and many of his students are now chiefs of service at medical centers throughout the United States and in a number of other countries. Literally hundreds of patients who were afflicted with conditions affecting the upper extremities were helped by his skill, his knowledge, and his patience. Perhaps because of his early experience in general medi- cine, he was an excellent diagnostician. Certainly because of his personality, he never said “no” to anyone, least of all to his patients. He was elected to more than 25 presti- gious surgical societies in the United States, Britain, France, and Italy. He was a member of the British Society for Colonel William KELLER Surgery of the Hand, the Groupe d’Étude de la 1874–1959 Main (GEM), and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT). On the evening of April 11, 1977, stu- Keller introduced his operation for bunions at the dents, colleagues, and friends gathered at the New very beginning of his surgical career, while he York Academy of Medicine to honor him, and the was working in Manila during the Philippine scientific program that night was made up of insurrection. Though it is now one of the most papers by his former students, many of whom are commonly performed operations, he was not very leaders in orthopedics and hand surgery in the interested in it, but went on to achieve fame in the United States. The following year time, he contributed much to his chosen field and he became a contract surgeon with the US Army, he proved much; he claimed very little. He moved kind and gentle, devoting himself selflessly, around hospitals in the USA and the Pacific until without thought to his own needs or strength, to the First World War, when he was assigned to the his work and to the alleviation of suffering wher- American Expeditionary Forces as Director of ever he found it. His massive contribu- time he developed an unroofing technique for tions to the medical literature were written in his empyema, a type of inguinal hernia repair, a adopted language, English, and it flowed with repair for recurrent shoulder dislocations (cruci- style, force, elegance, and precision. The roof kept the graft in position and the roof either disappeared by itself or could be removed. He was offered the post of Surgeon General, but refused because he wanted to continue clini- cal surgery. He remained at the Walter Reed until 169 Who’s Who in Orthopedics his retirement in 1935. He was one of those for- research assistant at the Institute of Orthopedics tunate people who only need 4 hours’ sleep a under Sir Herbert Seddon and was appointed con- night, and so have more time to work than most. Mary Abbot Hospitals On his retirement, he was, by special congres- in 1952. Here he established an orthopedic unit, sional legislation, made a consultant with pay and which became renowed. Lippy—as he was affec- allowances for life, the first man to be so honored tionately known to all—was especially concerned in US Army history. In 1953 an annual lecture with teaching junior orthopedic surgeons, and was named after him. During this time he took a keen interest in the hitherto rather neglected casualty services of this country, and played an important part in the eventual establishment of recognized accident and emergency departments, together with ade- quate training programs for the staff. Mary Abbots Hospitals, he was involved in the planning and smooth amalgamation of these hospitals with the Charing Cross Hospitals to form the existing New Charing Cross Hospital. At an age when most men would have begun to take life more easily, he accepted the post of director of clinical studies at the Institute of Orthopedics with his customary enthusiasm and dedication, and in 1974 he became professor of orthopedics of London University. He was able to foresee the problems that the postgraduate hospi- tals would face in the coming years, and set out to establish specialist departments at the Royal Lipmann KESSEL National Orthopedic Hospital that would help to 1914–1986 maintain its identity and reputation. In particular, he was largely instrumental in the setting up of Professor Lipmann Kessel was born in South the spinal injuries unit and a specialist shoulder Africa, educated at the University of Witwater- unit, his own particular lifelong interest. He later volunteered for articles about his early experiences with the para- parachute duties and, as surgeon in command of chute surgical team to many publications about a parachute team, took part in the battle of the shoulder joint, which remained his greatest Arnhem, where with exceptional skill and interest. He published several authoritative books courage he was directly responsible for saving on this subject and formed an international organ- many lives. When he had done all he could for ization for the study of the shoulder joint and the wounded, he managed to escape his German related diseases. He was executive member of the captors and, with the help of the Dutch Resis- council of the British Orthopedic Association and tance, eventually made his way home. These served on the editorial board of The Journal of experiences were related in his book Surgeon at Bone and Joint Surgery.

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Journal of Neurology buy cheap proventil 100 mcg line, Neurosurgery and Psychiatry 1993; 56: 311-313 Klüver H discount 100mcg proventil fast delivery, Bucy P discount proventil 100mcg mastercard. Cross References Apathy; Hypermetamorphosis; Hyperorality; Hyperphagia; Hyper- sexuality; Visual agnosia Knee Tremor A characteristic tremor of the patellae discount proventil 100 mcg line, sometimes known as knee bob- bing order 100mcg proventil mastercard, juddering, or quivering, may be seen in primary orthostatic tremor (POT; “shaky legs syndrome”). It is due to rapid rhythmic con- tractions of the leg muscles on standing, which dampen or subside on walking, leaning against a wall, or being lifted off the ground, with dis- appearance of the knee tremor; hence this is a task-specific tremor. Auscultation with the diaphragm of a stethoscope over the lower limb muscles reveals a regular thumping sound, likened to the sound of a distant helicopter. EMG studies show pathognomonic synchronous activity in the leg muscles with a frequency of 14-18Hz, thought to be generated by a central oscillator (peripheral loading does not alter tremor frequency). A number of drugs may be helpful in POT, including phenobarbi- tone, primidone, clonazepam, and levodopa, but not propranolol (cf. Archives of Neurology 1984; 41: 880-881 - 180 - Kyphoscoliosis K Brown P. Lancet 1995; 346: 306-307 Cross References Tremor Körber-Salus-Elschnig Syndrome - see NYSTAGMUS Kyphoscoliosis Kyphoscoliosis is twisting of the spinal column in both the anteropos- terior (kyphosis) and lateral (scoliosis) planes. Although such defor- mity is often primary or idiopathic, thus falling within the orthopedic field of expertise, it may also be a consequence of neurological disease which causes weakness of paraspinal muscles. Recognized neurological associations of kyphoscoliosis and scol- iosis include: Chiari I malformation, syringomyelia Myelopathy (cause or effect? Skeletal disease, such as achon- droplasia, is more likely to be associated with myelopathy than idiopathic scoliosis) Cerebral palsy Friedreich’s ataxia Neurofibromatosis Hereditary motor and sensory neuropathies Spinal muscular atrophies Myopathies, e. Some degree of scoliosis occurs in virtually all patients suffering from paralytic poliomyelitis before the pubertal growth spurt. Cross References Camptocormia; Stiffness - 181 - L Lagophthalmos Lagophthalmos is an inability to close the eyelid in a peripheral facial (VII) nerve palsy, with partial opening of the palpebral fissure. A sim- ilar phenomenon may be observed with aberrant regeneration of the oculomotor nerve, thought to be due to co-contraction of the levator palpebrae superioris and superior rectus muscles during Bell’s phe- nomenon. Cross References Bell’s palsy; Bell’s phenomenon; Facial paresis Lambert’s Sign Lambert’s sign is gradual increase in force over a few seconds when a patient with Lambert-Eaton myasthenic syndrome is asked to squeeze the examiner’s hand as hard as possible, reflecting increased power with sustained exercise. Cross References Facilitation Lasègue’s Sign Lasègue’s sign is pain along the course of the sciatic nerve induced by stretching of the nerve, achieved by flexing the thigh at the hip while the leg is extended at the knee (“straight leg raising”). This is similar to the maneuver used in Kernig’s sign (gradual extension of knee with thigh flexed at hip). Both indicate irritation of the lower lumbosacral nerve roots and/or meninges. The test may be positive with disc pro- trusion, intraspinal tumor, or inflammatory radiculopathy. Pain may be aggravated or elicited sooner using Bragard’s test, dorsiflexing the foot while raising the leg thus increasing sciatic nerve stretch, or Neri’s test, flexing the neck to bring the head on to the chest, indicating dural irritation. A positive straight leg raising test is reported to be a sensitive indi- cator of nerve root irritation, proving positive in 95% of those with sur- gically proven disc herniation. London: Imperial College Press, 2003: 362-364 Cross References Femoral stretch test; Kernig’s sign - 182 - Laterocollis L Lateral Medullary Syndrome The lateral medullary syndrome (or Wallenberg’s syndrome, after the neurologist who described it in 1895) results from damage (usually infarction) of the posterolateral medulla with or without involvement of the inferior cerebellum, producing the following clinical features: ● Nausea, vomiting, vertigo, oscillopsia (involvement of vestibular nuclei) ● Contralateral hypoalgesia, thermoanesthesia (spinothalamic tract) ● Ipsilateral facial hypoalgesia, thermoanesthesia, + facial pain (trigeminal spinal nucleus and tract) ● Horner’s syndrome (descending sympathetic tract), +/− ipsilateral hypohidrosis of the body ● Ipsilateral ataxia of limbs (olivocerebellar/spinocerebellar fibers, inferior cerebellum) ● Dysphagia, dysphonia, impaired gag reflex ● +/− eye movement disorders, including nystagmus, abnormalities of ocular alignment (skew deviation, ocular tilt reaction, environ- mental tilt), smooth pursuit and gaze holding, and saccades (lat- eropulsion) ● +/− hiccups (singultus); loss of sneezing. Infarction due to vertebral artery occlusion (occasionally poste- rior inferior cerebellar artery) or dissection is the most common cause of lateral medullary syndrome, although tumor, demyelination, and trauma are also recognized causes. Journal of Neuropathology and Experimental Neurology 1961; 20: 103-113 Pearce JMS. London: Imperial College Press, 2003: 233-236 Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP. Archives of Neurology 1993; 50: 609-614 Cross References Anesthesia; Dysphagia; Dysphonia; Environmental tilt; Gag reflex; Hemiataxia; Hiccup; Horner’s syndrome; Hypoalgesia; Hypohidrosis; Medial medullary syndrome; Nystagmus; Ocular tilt reaction; Oscillopsia; Saccades; Skew deviation; Sneezing; Vertigo Lateral Rectus Palsy - see ABDUCENS (VI) NERVE PALSY Laterocollis Laterocollis is a lateral head tilt; this may be seen in 10-15% of patients with torticollis. Cross References Torticollis - 183 - L Lateropulsion Lateropulsion Lateropulsion or ipsipulsion is literally pulling to one side. The term may be used to describe ipsilateral axial lateropulsion after cerebellar infarcts preventing patients from standing upright causing them to lean to toward the opposite side. Lateral medullary syndrome may be associated with lateropulsion of the eye toward the involved medulla, and there may also be lateropulsion of saccadic eye movements.

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