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Wladimir Solowiej 40 mg omeprazole visa, School of Medicine Alumni Scholarship a Baltimore physician who emigrated from Fund Income from an endowment provided Poland cheap omeprazole 20 mg overnight delivery. Solowiej nevertheless had high regard for School of Medicine Scholarship Fund By Johns Hopkins discount omeprazole 10 mg without prescription. The income from this fund action of the Board of Trustees of the Johns provides two scholarships, one in his name Hopkins University, a capital sum of $400,000 and one in the name of his sister, Augenia has been set aside, the income from which is Zebrowska. Seidel, Associate ship Established in 1998 by Arthur Sprague, Dean for Student Affairs. The fund will provide Fund Established in 1996 from the Estate of scholarships to needy students in the School Mildred C. Shaya Fund An endowed fund preference to be given to otherwise eligible established by Dr. The income is to provide scholarships High School, Frederick County, Maryland, to needy medical students. Its purpose is 1965, and his wife Evelyn M Strauch estab- to provide a loan resource for “deserving and lished this fund to commemorate his 35th needy students of the Johns Hopkins School class reunion. The income is lished for the purpose of providing traveling to be used to provide fnancial assistance to scholarships or fellowships for clinical study worthy students in the School of Medicine. Sutland Scholarship for Med- America or perhaps at times in the Orient, ical Education This scholarship was estab- especially the Philippines. The income of this fund is to pro- Simon, Class of 1937, was a plastic surgeon vide scholarships to needy medical students. Morris Slemons Scholarship Fund Wasserman established this fund in honor of Established by a bequest from Anne G. This fund provides fnan- mons to be used for scholarships for medical cial assistance to needy medical students, students. This scholarship fund was established in Vander Salm graduated from the School 2003. Scholarship for Medical Education Estab- Income from this fund will provide fnancial lished in 2000. Wexler in 1995 to provide an annual award This fund was established in 1998 by the for a graduating student with an interest in estate of Dr. Wakefeld to provide scholar- multiple sclerosis, heart disease, blindness/ ships for students in need of additional funds diseases of the eye, cancer/oncology-hema- to continue their education. Arthur Nathan Wang Memorial Schol- Frances Turner White Fund This fund, arship Fund This fund was created in 1988 established with a gift from the estate of Fran- in honor and in memory of Dr. Arthur Nathan ces Turner White, provides scholarships for Wang, an alumnus of the School of Medi- needy and deserving medical students. Raymond Wing Memorial Scholarship rosurgeon was tragically ended early in his Fund This fund was established in 1981 by life by a fatal accident. Raymond Wing to honor the memory fund each year will provide a scholarship to of her husband, a member of the School of a needy and deserving student who intends Medicine Class of 1927. In for students in their frst year of study at the establishing the fund, the family and friends School of Medicine. Wang hope to help others to complete Winslow Foundation Scholarship Fund the contribution to medicine and society Gifts have been received annually since 1974 begun by him. Waring, an endowment in Charles Marion Wolfe Scholarship Fund memory of her husband has been estab- The Fund was established in 1997 through lished in the School of Medicine, the income the estate of Doris L. Wolfe in memory of her from which is to be used as a scholarship husband, Charles Marion Wolfe, to be used fund for needy and worthy students. Zepp to be rial Scholarship This fund was established used in support of the education of medical in 1996 from the Gladys C. Scholarship Fund This fund was established in 1998 in mem- Watt/Hansell Endowment This fund was ory of Dr. Wegman to provide and opportunity students with preference to those planning for medical students to pursue public health careers in pediatrics. The fund is managed jointly by the Deans of the School of Medicine and Public Health. Theron Hunter Loan Fund Established by Barton have contributed a memorial fund in Dr. In view of Miss Barton’s interest be used for aid in the form of loans to deserv- in young people, the fund is used to assist ing students in the third and/or fourth year medical students who are not in a position to classes of the School of Medicine. Boswell Loan Fund This fund provides Alumnae Association Student Loan Fund loans for medical students. Cargille Student Loan provide fnancial assistance to medical stu- Fund was established in recognition of Dr.

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Missed angulation purchase omeprazole online pills, Colles dependent upon fractures quality omeprazole 10mg, this is fracture angulation and more common preferance of with fracture of orthopedist purchase omeprazole 40mg mastercard. The wrist joint includes the dis- tal articular surfaces of the radius and ulna, as well as the proximal and distal carpal rows. Reprinted from Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed. Two sets of volar ligaments and one set of dorsal ligaments support the carpal bones. The Scaphoid and lunate articulate with the distal radius, the ulna articulates with a fibrocartilagenous structure known as the triangular fibrocartilage (abv. The scaphoid, lunate and capi- tate bones are supplied by a single vessel which predisposes them to avascular ne- crosis especially with proximal fractures. The scaphoid by far the most commonly injured bone and is palpable within the anatomical snuff box which is bordered by the distal radius and the extensor policis longus and brevis tendons. A bony land- mark called Listers tubercle is located on the dorsal aspect of the distal radius just ulnar to the extensor pollicis longus tendon (Fig. There are however some specific traumatic mechanisms that are associated with specific injuries. Physical Exam As with all fractures, point tenderness over a bone suggests fracture or significant injury. There are, however, specific maneuvers which are associated with individual carpal injuries as follows. Other views may be helpful to elucidate individual injuries if suspected, please refer to table. It is important to understand the normal radiographic anatomy when interpreting wrist X-rays. The radial styloid projects beyond the distal ulna and the distal radius has a volar tilt of 10-25 degrees in lateral projection (Fig. The capitate lunate and distal radius should align on the lateral projection and the long axis of the scaphoid should intersect at 30 to 60 degrees (Fig. The distance between carpal bones should be uniform and about 2 mm; any increase suggests ligamen- tous disruption. Diagnosis Treatment and Disposition Injuries to the wrist must be treated carefully. All fractures or suspected fractures should be immobilized with thumb spica splint in neutral position. Special radio- graphic views should be ordered if specific injuries are suspected. There is also significant risk of radiographically occult injuries, particularly of the scaphoid and lunate. Plain ra- diographs miss up to 15% of scaphoid fractures, for this reason, wrist injuries Orthopedic Emergencies 217 Figure 8. A) The normal scapholunate angle is formed by the intersection of the longi- tudinal axes of the scaphoid and lunate and normally measures 30-degrees. B) The nor- mal capitolunate angle is formed by the intersection of the capitate and lunate central long axes and normally measures 0-30 degrees. Reprinted from Rosen’s Emergency Medi- cine: Concepts and Clinical Practice, 5th ed, ©2002 Mosby/Elsevier, with permission. Any neurovascular injury or displaced fracture requires immediate orthopedic consultation. Injury X-Ray Views and Findings Treatment and Disposition Scaphoid Scaphoid views; displaced All fractures or suspected fractures fracture fracture is >1 mm require immobilization in neutral position with thumb spica splint. A diastasis of 3 mm Orthopedic consultation dissociation or more known as a “Terry Thomas for surgical repair sign” is pathognomonic. Examination • The examination of the hand should proceed in an orderly and deliberate way. The next step is palpating for peripheral pulses and checking for normal capillary refill (<1-2 sec). With the fist in the closed position the examiner occludes both the radial and ulnar arteries by applying pressure at the wrist. As the patient opens their fist the pressure is released over one of the arteries. This test should be re- peated with occlusion of the opposite artery to assess adequate blood flow from both the ulnar and radial arteries. Failure of the hand to immediately flush indicates partial or complete compromise of either the radial or ulnar arterial supply to the hand. A Doppler should be used in situations when the examiner is unable to palpate periph- eral pulses. Orthopedic Emergencies 219 • Gross sensory testing • The radial zone is the first dorsal web space between the thumb and index finger. If a sensory deficit is detected one should also suspect digital artery injury as the artery and nerve run closely together.

It appears to be well tolerated and has been shown reduce both behavioural disturbance in patients and distress in carers order 20 mg omeprazole visa. Therefore its use is strictly confined to ‘mild to severe’ dementia of the Alzheimer type order omeprazole 20mg. Memantine should be avoided with severe renal impairment and caution 2809 should be exercised in cases of epilepsy purchase omeprazole 10 mg amex. Uncommonly, memantine may cause hallucinations, confusion, 2802 Weigh patient at intervals. The starting dose is 5 mg (half a tablet) per day; each week the daily dose is increased by 5 mg; and the recommended maintenance dose is 20 mg per 2810 day. Combined memantine added to donepezil may produce increased gains in terms of global outcome, activities of daily living, behaviour, and cognition. It seems to have acetylcholinesterase activity but with little effect on butylcholinesterase. There is some evidence of efficacy when used alone or in combination with ginkgo biloba. However, DeKosky ea (2008) assigned 3,069 community volunteers aged at least 75 years with either normal cognition or mild cognitive impairment to either placebo or ginkgo biloba 120 mg twice daily and followed them up for a median of 6. Whilst the vinca alkaloid vinpocetine improves learning and memory in animals it does not benefit dementia sufferers. A number of secretases are involved in beta-amyloid peptide (40-42 amino acids) production from amyloid precursor protein. R-flurbiprofen, a gamma-secretase modulator, leads to shorter amino acids that do not lead to Aβ accumulation. Hypercholesterolaemia accelerates amyloid pathology and reduced cholesterol intake slows plaque 2814 development in transgenic mouse models, a finding that may have some application in humans. However, because more educated people may be more likely to take such drugs, the effects of education have to be controlled for in research. Ginkgo biloba, from the leaves of the maidenhair tree, was used in Chinese medicine for millennia; concerns have been raised over a tendency to cause bleeding. The ‘essential oil’ contains cineole, borneol and thujone and the leaf contains many chemicals such as oleic and tannic acids. There may be thrombosis of leptomeningeal or cortical vessels leading to many small infarcts. There is evidence for an increased risk for dementia in people with affective disorders (e. Most studies were of short duration, they were more often unpublished, and they were usually funded by the pharmaceutical industry. Schneider ea (2006) found adverse effects of atypical antipsychotic drugs for treatment of psychosis, aggression, or agitation in Alzheimer patients outweighed any therapeutic advantages. Sultzer ea (2008) used antipsychotic drugs for psychosis or agitated/aggressive behaviour in outpatients with Alzheimer’s disease: the drugs were useful for certain symptoms (e. Conventional antipsychotic drugs may carry similar risks for mortality when used in demented subjects. In the substantia nigra they are brightly eosinophilic (pink) with hyaline core and paler halo; in cortex they are faintly eosinophilic and have no core. They were considered confined to idiopathic Parkinson’s disease 2822 (paralysis agitans) until recent years. Friedrich Heinrich Levy (1885-1950) discovered these bodies in the brains of Parkinson’s disease patients in 1912 when with Alzheimer at Kraepelin’s Royal Psychiatric Clinic in Munich. Bennett ea (2006) prospectively reported that 7-14% of non-demented/non-cognitively impaired people who died had Lewy body pathology. Lewy bodies contain ubiquitin and alpha-synuclein and antibodies to these proteins can be used in postmortem tissue as a method of detecting these bodies. The dose of alpha-synuclein (number of genes) may play a role in the aetiology of dementia. In Parkinson’s disease up to 70% of cells are lost from the substantia nigra before symptoms manifest themselves. Cognitive decline has correlated with both neuroleptic usage and with persecutory ideas! L-deprenyl has been suggested for Parkinsonism but it may precipitate hallucinations. Atypical antipsychotic drugs may cause as many problems do as typical agents, although olanzapine, quetiapine, aripiprazole or clozapine may be useful. The usual visual hallucinations are of people or animals that may disappear when the patient stares at the image. Also, the patient may see (illusions) things such as a face in detailed objects like a bush. The German neuropathologist Friedrich Heinrich Lewy (1885-1950), while working with Alzheimer, described spherical neuronal inclusions.

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Chronic cholecystitis and clinical settings associated with physiologic failure of the gallbladder to fill with radiotracer (e order 20mg omeprazole visa. In chronic cholecystitis 40 mg omeprazole visa, the gallbladder will usually be seen within 30 min of morphine administration or on 3- to 4-h delayed images omeprazole 20 mg without a prescription, whereas true cystic duct obstruction (acute cholecystitis) will result in persistent gallbladder nonvisualization. A gallbladder that is not visualized until after the time that the bowel is visualized correlates significantly with chronic cholecystitis. Delayed biliary-to-bowel transit beyond 60 min raises suspicion of partial obstruction of the common bile duct, although this may be seen as a normal variant in up to 20% of individuals. With high-grade common bile duct obstruction, there is usually prompt liver uptake but no secretion of the radiotracer into biliary ducts. With partial biliary obstruction, radiotracer fills the biliary system but clears poorly proximal to the obstruction by 60 min or on delayed images at 2–4 h or with sincalide. Severe hepatocellular dysfunction may also demon- strate delayed biliary-to-bowel transit. A bile leak is present when tracer is found in a loca- tion other than the liver, gallbladder, bile ducts, bowel, or urine. Leakage may be seen more easily using a cinematic display or decubitus positioning, as described above. Biliary atresia can be excluded scintigraphically by dem- onstrating transit of radiotracer into the bowel. Failure of tracer to enter the gut is consistent with biliary atresia but can also be caused by hepatocellular disease or immature intrahepatic transport mechanisms. Renal or urinary excretion of the tracer (especially in a diaper) may be confused with bowel activity and is a potential source of erroneous interpretation. During a hepatobiliary scan, activity may reflux from the duodenum into the stomach. Bile reflux that is marked and occurs in a symptomatic patient corre- lates strongly with bile gastritis, a cause of epigastric discomfort. After cholecystectomy, sphincter of Oddi dysfunction has the appearance of partial common bile duct obstruc- tion. Pretreatment with sincalide or morphine may improve the sensitivity for its detection. Various visual, quantitative, and semiquantitative scintigraphic param- eters of bile clearance have been used in conjunction with image analysis. The causes of a false-positive study (gallbladder non- visualization in the absence of acute cholecystitis) include: a. Severe intercurrent illness (despite sincalide pre- treatment and morphine augmentation) f. Rapid biliary-to-bowel transit (insufficient tracer activity remaining in the liver for delayed imaging) h. Previous cholecystectomy The causes of a false-negative study (gallbladder vis- ualization in the presence of acute cholecystitis) are rare but include: a. A bowel loop simulating gallbladder (Drinking 100–200 mL water may remove the radiophar- maceutical from the duodenum and allow differ- entiation of gallbladder from bowel. A right lateral view should be obtained to better distinguish activity in the duodenum from that of the gallbladder. The presence of the dilated-cystic-duct sign simu- lating gallbladder (If this sign is present, morphine should not be given. Description of findings Include the appearance of the liver, intrahepatic ducts, common bile duct, the presence and time of tracer appear- ance in the gallbladder or small bowel, any unusual activity (e. Study limitations (patient reactions to drugs adminis- tered) If there is an allergic or other adverse reaction to the radiopharmaceutical or other administered pharmaceuticals, the reaction must be clearly stated in the findings and impres- sion sections of the report. Gastrointestinal symptoms elicited by sincalide infusion are related to the rapid infusions and are not observed with the recommended slower infusion techni- ques of 45 and 60 min. Gastrointestinal symptoms occurring during the shorter sincalide infusion have no specificity for gallbladder pathology (93) and should not be part of the study report. However, no information about possible pla- cental crossover of hepatobiliary compounds is available. Impression The impression should be concise and as precise as pos- sible, should address the clinical question, should provide a differential diagnosis, and should make recommendations if appropriate. Any urgent or unexpected findings should be directly communicated to the referring physician, and this communication should be documented. Radiation dosimetry in adults, children, and pregnant or potentially pregnant patients is presented in Tables 2–4. The physician must consider the indication for the test, the potential benefit of information it may provide toward improved care of the patient, and the potential risk it may pose to the fetus. The role of sincalide choles- cintigraphy in the evaluation of patients with acalculus gallbladder disease.

The College incorporates the Irish Psychiatric Training Committee purchase discount omeprazole on line, the Irish College of Psychiatrists buy omeprazole 20mg visa, and the Irish Psychiatric Association purchase omeprazole paypal. According to Nolan (1991), the introduction of courses and certificates did little to improve the lot of attendants, and may have helped to prompt the formation of unions in protest at poor working conditions. Lena Peat of Warlingham Park Hospital, Surrey, with the backing of the hospital’s medical superitentent T 4002 P Rees, became the first community psychiatric nurse in Britain in 1954. A nursing post created to look after the chronically ill in the community has become increasingly aligned with primary care and, arguably, 4003 the less severely ill. Project 2000 in England removed nurse education from hospitals (apprenticeship model) and into 4004 universities (theoretical model). An 18-month foundation programme was followed by a further 18- month period of largely theoretical specialisation. Gournay (2001) suggested that an anti-psychiatry ambience may be alive and well in ‘many university departments of nursing’ and he bemoaned the loss of those elements of apprenticeship ‘which are so valuable to the training of nurses’. Similar trends have appeared in Ireland in recent years, compounded by a serious lack of entrants to nurse training. Apart from pay and career issues, the present author does not believe that matters are helped by the closure of (cheap) nurses’ homes and the (prohibitive) ‘points system’ employed by universities to award places in nursing departments. There is 4005 also the danger that newly qualified nurses will not wish to undertake many traditional nursing duties. Child Psychiatry Elementary school attendance was made compulsory in Britain in 1880, highlighting a ‘surprisingly high proportion’ of poor copers due to learning (syn. The first asylum in Britain dedicated to this group was The Asylum for Idiots, Park House, Highgate in London, established two years later. H Bickel, J Gerrard and E M Hickmans reported in 1953 that removing phenylalanine from the diet of children with phenylketonuria prevented further intellectual deterioration. Some historical aspects of drug treatments in psychiatry 4007 Perhaps the oldest drug is mead , fermented from honey. Chloral hydrate was synthesised by Justus Von Liebig in 1832 and introduced by Liebreich as a hypnotic in 1869. Barbituric acid, (malonylurea) prepared by Von Baeyer in the 1860s and named after St Barbara, gave rise 4012 to a new group of synthetic psychotropics, the barbiturates. Opiates and scopolamine were also used for a time in psychiatry, to quieten disturbed patients. Julius Wagner-Jauregg (1857-1940) 4017 Again in Vienna, Manfred Sakel used injections of insulin in 1927 to induce hypoglycaemic coma. The extra care given by enthusiastic staff 4009 Now chloral betaine, a pro-drug that must be metabolised to trichlorethanol to produce its hypnotic effect. Chloral hydrate with alcohol (Mickey Finn) was used to knock out sailors who were being shanghaied. Trichlorethanol slows ethanol metabolism and the latter quickens chloral hydrate’s conversion to trichlorethanol. It had to be administered in a glass syringe and could cause metabolic acidosis, sterile abscesses, nerve damage and sloughing of skin. Paraldehyde is not as safe in people with liver dysfunction as once thought and is mostly metabolised by the liver with only a small proportion being excreted via the lungs. The toxicity and dependence associated with barbiturates have severely restricted their use. Suphonal, a powerful tranquilliser derived from acetone in 1886, is no longer in use. Diphenylhydantoin (phenytoin), a much less toxic agent than phenobarbitone, was discovered by Merritt and Putnam (1958) from the examination of a series of phenyl compounds. Insulin therapy fell into disuse because coma induced by 4018 barbiturates gave equally good results. Ladislas Von Meduna believed, erroneously, that schizophrenia and epilepsy could not co-exist. After using camphor oil to induce convulsions he switched to Cardiazol (soluble solution of synthetic 4021 camphor ) in 1934. Other agents were eventually added to the list of epileptogens, such as picrotoxin. This was later modified by the use of a general anaesthetic and a muscle relaxant. He then worked with Otfrid Foerster in Breslau on the removal of atrophic epileptiform lesions, leading to an enormous number of operations on epileptics in later years. Egas Moniz, the originator of cerebral angiography, founded modern psychosurgery by cutting pathways in the prefrontal areas in 1935. Antipsychotic drugs 4023 Reserpine (a Rauwolfia alkaloid) - used for many of purposes, including the treatment of psychosis Methylene blue - has a phenothiazine nucleus and was used briefly as an antipsychotic Phenothiazine - synthesised by August Bernthsen in 1883; first used as an antihelminthic in 1934 4024 Chlorpromazine - synthesised by Charpentier in 1950 at Rhone-Poulenc laboratories 4025 Laborit used chlorpromazine to induce artificial hibernation during operations, noticing a certain ‘detachment’ in his patients 4018 The analyst Smith Ely Jelliffe believed insulin therapy to work by ‘withdrawing the libido from the outside world and fusing it with the death impulse for the maintenance of the narcissistic ego’! Electrification of the skin was the therapeutic aim at first, but later on the electrodes were applied to the head (Beveridge and Renvoize, 1988).

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It is likely that all these conditions result in a degree of myocardial damage; hence discount 40mg omeprazole, they are not really ‘false positives’ purchase omeprazole 40mg with mastercard. During and soon after thrombolysis or angioplasty generic omeprazole 10 mg without prescription, ventricular arrhythmias are commonly seen. Atrial fibrillation is also treated with amiodarone, or sometimes digoxin is given for rate control. Heart block: This maybe present in the acute stage, and maybe first degree, second degree or complete. Recurrence of chest pain, either at rest or on mild exertion could be due to post infarction angina or re-infarction. Treatment is usually by increasing antianginal therapy – nitrates, beta blockers and calcium channel antagonists. Post infarction angina is an indication for early coronary angiography, to determine if re-occlusion has occurred, and to exclude other critically narrowed coronary artery branches. Acute myocardial ischaemia 141 Handbook of Critical Care Medicine Right ventricular infarction: Patients present in the acute stage with hypotension, congested neck veins, and clear lungs. Low blood pressure is due to reduced right ventricular contractility resulting in reduced left sided filling pressures. Careful administration of fluids will normalise the blood pressure; inotropes are sometimes needed. Papillary muscle rupture is a serious complication, presenting suddenly with pulmonary oedema and hypotension. Intra-aortic balloon pumping may be necessary; surgical repair is mandatory, without which the mortality is high. Cardiac tamIt is more common in the elderly, and in patients who did not receive thrombolyis. Pleuritic chest pain, pericardial friction rub, fever, leukocytosis, and sometimes pleural effusion or pulmonary infiltrates are seen. Treat with inotropes (dobutamine, Prognosis significantly worse than I adrenaline) and diuretics and nitrates. Definition: The rapid onset of symptoms and signs secondary to abnormal cardiac function. Acute heart failure is a dangerous and life threatening condition, which requires early recognition and aggressive treatment. The patient will be tachypnoeic, and will have bilateral fine crackles, and may have a wheeze. Management Monitoring – connect the patient to a continuous cardiac monitor and pulse oxymeter. Airway: clear secretions, open the airway (see section on airway management), if necessary use an oral airway. Breathing: dyspnoea and tachypnoea are the cardinal features of acute heart failure. Circulation: if the patient is hypotensive, fluid resuscitation and inotropes may be necessary, bearing in mind that fluid resuscitation may worsen pulmonary oedema. It is elevated in systolic and diastolic failure, but not in other causes of acute dyspnoea. Even if in doubt of the diagnosis, if the patient’s blood pressure is stable, diuretics will do little harm. Doses up to 400mg of frusemide maybe necessary in severe left ventricular failure. Frusemide can be given as a continuous infusion of 10-20 mg/hour, with dose reduction according to response. These are: Upper lobe diversion of blood Perihilar congestion Kerley B lines Pleural effusion Afterload reduction: If the blood pressure is high, it will increase the load on the heart and worsen heart failure. Sublingual and intravenous nitrates are used to lower systemic vascular resistance and improve heart failure. It acts by causing pulmonary venodilatation, and also by alleviating anxiety and calming the patient. It also improves cardiac output by reducing ventricular transmural pressure and thereby reducing afterload. Fluid therapy: It is important to ensure that circulating volume is adequate, as this will affect preload. Failure to optimise fluid volume will result in a further drop in blood pressure with diuretics. Correction of arrhythmias: Tachyarrhythmias compromise cardiac output and worsen heart failure. When the heart rate increases, diastole shortens more than systole, resulting in reduced ventricular filling time, and hence reduced preload.

If cures can be achieved by a fusion o f the patient’s belief in the treatm ent and the manifestation o f symbols of healing generic omeprazole 10mg with mastercard, we must ask if it is possible to use equally effective but less expensive symbols purchase omeprazole pills in toronto. For centuries healers have adm inistered to pa­ tients cheap omeprazole 40 mg without prescription, with little impact if m easured by the test of effective­ ness. But medicine worked in the past and still works today, although with mixed results. Medicine has effective technologies— technologies that link what the physician does with what happens to the patient. Most of the research was designed to ascertain optimal conditions for the production of goods. But the investigators discovered an anomaly—whatever they did, 20 The Impact of Medicine production improved. W hen workers believed that m anagem ent cared, w hether by increasing or decreasing the lighting, for example, they tried harder. Some patients given placebos respond better to the null “treatm ent” than those given active drugs. In some studies, groups of patients given placebos had better treatm ent outcomes than groups treated with active medications. One of the dangers, then, of too rigorous an examina­ tion of medicine—requiring proof beyond a reasonable doubt—is that caring might be lost in the process. In procedures such as reduction of frac­ tures; treatm ent of infectious diseases such as diphtheria, tetanus, poliomyelitis, and tuberculosis; and surgery for re­ moval of pathenogenic organs, the physician truly heals. Medical care also heals when it utilizes therapies with which The Impact of Medical Care on Health Status 21 it has been entrusted. Penicillin, sulfa drugs, and antibiotics have expanded the capacity of the medical care system to treat and heal. The capacity to deal effectively with syphilis and tuberculosis represents a milestone in human endeavor, even though full use of this potential has not yet been made. And there are, of course, other examples: the treatment of endo- crinologic disorders with appropriate hormones, the preven­ tion of hemolytic disease of the newborn, the treatment and prevention of various nutritional disorders, and perhaps just around the corner, the management of Parkinsonism and sickle-cell anemia. There are other examples, and everyone will have his favorite candidate for the list, but the truth is that there are not nearly as many as the public has been led to believe. T he Papanicolaou test for cervical cancer has proven utility,39 and the means have been found to treat some forms of skin cancer. Paradoxically, some diseases that are both preventable and treatable continue to strike large num bers of people. Allen Chase in The Biological Imperatives40 lists a num ber of preventable diseases which either kill or debilitate large num bers of people simply because resources have not been allocated to their control. Included are hookworm disease, which afflicts approxim ately 600 million people; ascariasis, 22 The Impact of Medicine another worm infestation; schistosomiasis; trachom a, which causes irreversible blindness; and endemic goiter. T he fact that most of these diseases are ram pant in underdeveloped areas does not make them irrelevant. Even in the United States there are diseases that could be m ore effectively treated, or possibly even prevented. Edward Berk, Chairm an o f the D epartm ent of Medicine at the University of California at Irvine, m ore than half of the population o f the United States registers frequent complaints about digestion. Roughly 15 to 20 percent of all illnesses reported afflict the digestive tract—the stomach, intestines, biliary passages, liver, and pancreas. Because of nonspecific symptoms, many cases of peptic ulcer and gallstones, for example, re­ main undetected. Nevertheless, digestive disease ranks second only to circulatory disorders as a cause of workdays lost per year. And research funds are disproportionately spent in other areas, particularly those that have strong lobbies, such as cystic fibrosis and muscular dystrophy. Despite its limitations and despite its questionable priorities, the medical care system continues to grow and consume m ore and m ore resources. Some of the most trenchant thinking about the effectiveness o f medical care has been done by A. In Effectiveness and Efficiency,43 Cochrane concludes that the National Health Service has had little to do with improving mortality and morbidity rates. He acknowledges the effectiveness of some medications for some conditions; strikes a loud note for preventive measures such as im m uni­ The Impact of Medical Care on Health Status 23 zation and curtailm ent o f population growth and cigarette smoking; expresses doubt about some tried and true mea­ sures, including the pap sm ear and the coronary care unit; and, almost hesitatingly, argues that further developm ent of medical therapies should be deferred until definitive proof of their effectiveness is available. T o read Cochrane is to conclude with him that little of medical care is effective and that health will never be the exclusive product of medical care—there are too many other factors. W hen somebody gets the flu, the advice given by both the professional practitioner and the am ateur diagnostician is the same—wait it out. Several researchers have established the rarity of cancers, vascular disorders, and other degenerative diseases am ong primitive popula­ tions. Unique geographical and cultural factors affect both the incidence and control of certain dis­ eases. In the nineteenth century, at the height of the Industrial Revolution, thousands of migrants were compressed into urban industrial sinks. But despite the hum an loss, enorm ous in some cases, people in most affluent countries have adopted to urban conditions (and, of course, the conditions have been im proved as well).

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