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By I. Samuel. Tuskegee University. 2018.

Over the past twenty years personal behaviour has been exten- sively re-interpreted and reorganised around considerations of health order viagra super active 25mg amex does gnc sell erectile dysfunction pills. The very ubiquity of terms which link ‘health’ with some activity which had previously been regarded as a distinct and autonomous sphere indicates this trend—‘healthy lifestyle’ purchase 25 mg viagra super active mastercard reasons erectile dysfunction young age, ‘health 67 SCREENING foods’, ‘healthy eating’, ‘sexual health’, ‘exercise for health’. Whereas feminists once rejected ‘women’s health’ as a form of male medical domination, their latter-day sisters have embraced ‘lesbian health’ as an affirmation of identity; in a common spirit of victimhood we now also have ‘men’s health’. The cult of exercise, pursued not for the enjoyment of sporting activity as such, but in the cause of improving physical fitness in the abstract, reflects the ascendancy of preoccupations about health over personal behaviour. The third theme is the transformation of the medical role and the emergence of new institutions that mediate between the individual and the state in the sphere of health. The change in the role of the doctor is most apparent in general practice, in many ways the front line of the advance of medical intervention in lifestyle. In the not-so- distant past, general practice was a demand-led service: patients came to the surgery complaining of illness and doctors offered diagnosis and treatment, care and concern, within the limits of their own abilities and those imposed by medical science and health service resources. Over the past decade, general practice has shifted to a more pro-active approach, inviting patients to attend for health checks and screening procedures and adopting a more interventionist role in relation to lifestyle issues, such as smoking and drinking, diet and exercise. Instead of serving their patients’ needs, GPs now serve the demands of government policy—and the dictates of government-imposed health promotion performance targets. New procedures, such as the routine check-up and the lifestyle questionnaire, allowing the systematic recording (now in a readily accessible computerised form) of intimate knowledge of the patient, have become a familiar feature of the doctor-patient relationship. Having taken on a major role in health promotion, the government has worked with the established organisations of the medical profession—the various royal colleges, the BMA and others—to push forward initiatives like the Health of the Nation campaigns of the early 1990s. It has also recognised the limitations of these traditionally conservative and inflexible bodies and has encouraged the development of a range of institutions to play a more dynamic role. An early example of this approach was the establishment of the Health Education Council in 1968; this was transformed into the Health Education Authority in the heat of the Aids crisis twenty years later and was finally wound up in 2000 as its functions were subsumed by New Labour’s Health Development Agency and other public health initiatives. The internal controversies 68 SCREENING of this body— and its well publicised tensions with government— reflect some of the difficulties involved in developing a novel health promotion approach (Farrant, Russell 1986). The anti-smoking campaign ASH, formed in 1971 with funding from the Department of Health, provided a model for numerous health-oriented voluntary organisations and pressure groups which flourished from the 1980s onwards, popularising health promotion messages. The big Aids charities—notably the Terrence Higgins Trust and the National Aids Trust—both heavily reliant on government funding, played a major role in the safe sex crusade. As we have seen, the big cancer charities have complemented the activities of the national screening agencies in encouraging women to have smears and mammograms. Together with new health organisations and campaigns came a new corps of health professionals, skilled in the techniques appropriate to the advance of health promotion. Some of these were doctors, many more were nurses, only too keen to adapt their traditional skills to the requirements of the new discipline. While campaigning groups oriented towards politicians and the media required organisers, fund-raisers and journalists, those engaging with the public required skills in counselling in general, often combined with more specific expertise, required for example to give advice about diet, sexual behaviour or ‘smoking cessation’. The exercise cult has provided employment for numerous personal trainers, aerobics instructors and others, who are now likely to have received basic health promotion training. The fact that activities once proscribed as sinful—gluttony, sloth, lust—are now regulated in the name of health has led numerous commentators to draw parallels between the ascendancy of health promotion over lifestyle today and the rule of religion in the past. The common features are indeed striking: the devotion to the cause of fitness displayed by the faithful, the spirit of self-denial required to sanctify the body, the zealotry of the newly converted, the dogmatism of the clergy. It appears that health provides some compensation for the decline of traditional religion, both as a focus of individual aspiration and as a secular moral framework for society. The focus of health promotion on lifestyle risk factors for disease emphasises individual responsibility and demands compliance with 69 SCREENING the appropriate medically-sanctioned standard of behaviour as a duty to society. The burden of personal responsibility is reinforced by elevation of risks to others that may arise from individual failings: hence the emphasis on ‘innocent victims’ of HIV/Aids (children, haemophiliacs), the passive smoker, the foetus (of smoking, drinking, drug-taking mothers). Since traditional moral sanctions on behaviours considered deviant have become ineffective as a result of the declining power of the churches in society, values derived from health promotion have acquired growing influence. As the American historian Francis Fukuyama has noted, ‘we feel entitled to criticise another person’s smoking habits, but not his or her religious beliefs or moral behaviour’ (quoted in Thomas 1997).

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You have particular responsibilities as the initial leader of the group but your role will vary considerably both within a session and from session to session discount viagra super active 100 mg fast delivery impotence young men. For instance purchase 100 mg viagra super active amex latest erectile dysfunction drugs, if you adopt an autocratic or authoritarian style of leadership (not an uncommon one among medical teachers) you may well have a lot of purposeful activity but there will be a limited amount of spontaneous participation. You should pre- ferably adopt a more co-operative role where you demonstrate an expectation that the students will take responsibility for initiating discussion, providing informa- tion, asking questions, challenging statements, asking for clarification and so on. A successful group is one that can proceed purposefully without the need for constant intervention by the teacher. This is hard for most teachers to accept but is very rewarding if one recognises that this independence is one of the key goals of small group teaching and is more important than satisfying one’s own need to be deferred to as teacher and content expert. These are factors relating to the task of the group and factors relating to the maintenance of the group. In addition there must be a concern for the needs of each student within the group. The tasks of the group: clear definition of tasks is something that must be high on the agenda of the first meeting. The reason for the small group sessions and their purpose in the course must be explained. In addition, you should initiate a discussion about how you wish the group to operate, what degree of preparation you expect between group meetings, what role you intend to adopt, what roles you expect the students to assume and so on. Because such details may be quickly forgotten it is desirable to provide the students with a handout. Ideally it is one that is open, trustful and supportive rather than closed, suspicious, defensive and competitive. It is important to establish that the responsibility for group maintenance rests with the students as well as with the teacher. The firm but pleasant handling of the loquacious or dominating students early in the session or the encouragement of the quiet student are obvious examples of what can be achieved to produce the required environment for effective group discussion. The successfully managed group will meet the criteria shown in Figure 3. A structured approach to tasks and to the allocation of the time available is a useful tool for you to consider. An example of such a structured discussion session is illustrated in Figure 3. Note that the structure lays out what is to be discussed and how much time is budgeted. Such a scheme is not intended to encourageundue rigidity or inflexibility, but to clarify purposes and tasks. This may seem to be a trivial matter, but it is one which creates considerable uncertainty for students. You need to be alert to how time is being spent and whether time for one part of the plan can be transferred to an unexpected and important issue that arises during discussion. Another structure, not commonly used in medical educa- tion, is illustrated in Figure 3. From an individual task, the student progresses through a series of small groups of steadily increasing size. There are special advantages in using this structure which are worth noting: it does not depend on prior student preparation for its success; the initial individual work brings all students to approximately the same level before 45 discussion begins; and it ensures that everyone partici- pates, at least in the preliminary stages. INTRODUCING STIMULUS MATERIALS A very useful means of getting discussion going in groups is to use what is generally known as ‘stimulus material’. We have seen how this was done in the snowballing group structure described previously. It is limited only by your imagination and the objectives of your course. Here are a few examples: A short multiple-choice test (ambiguous items work well in small groups). X-rays, photographs, slides, specimens, real objects, charts, diagrams, statistical data). A journal article or other written material (an interesting example is provided by Moore where he used extracts from literary works to help students understand the broader cultural, philosophical, ethical and personal issues of being a doctor. Examples of sources of these extracts included Solzhenitsyn’s Cancer Ward and Virginia Woolf’s On Being III).

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We encountered 16 patients with slipped capital 1Department of Orthopedic Surgery discount 25 mg viagra super active amex impotence liver disease, Tokyo Medical University Hachioji Medical Center generic viagra super active 100 mg without a prescription erectile dysfunction causes heart, 1163 Tatemachi, Hachioji, Tokyo 193-0944, Japan 2Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan 69 70 M. Subjects and Methods The subjects were 16 patients (12 boys and 4 girls) encountered during the previous 16-year period. The evaluation items were chief complaint, mechanism of injury, initial diagnosis, disease type, radio- graphic findings such as the slipping angle, physique and endocrinological abnor- malities, treatment methods, and complications. For radiographic evaluation, the head–shaft angle on frontal images and the pos- terior tilting angle in the frog-leg position were measured, and the right–left differ- ence was regarded as the slipping angle. The severity of the disease was evaluated mainly based on the posterior tilting angle. Results The chief complaint was hip joint pain in 11 patients, pain from the hip joint to the knee in 3, pain from the hip joint to the thigh in 1, femoral pain in 1, and lower limb pain in 1. The mechanism of injury was sports in 8 patients, falling during running in 1, falling on the stairs in 1, long-distance walking in 1, and unknown in 3: most patients had relatively mild injuries. The mean interval between the onset of symp- toms to the initial visit to the hospital was 69 days and that from the initial visit to diagnosis was 30 days. The duration until diagnosis was relatively short in patients with acute slip but considerably longer in some patients with chronic or acute on chronic slip. The coefficient of the correlation between the onset of symptoms and diagnosis was 0. The initial treatment was performed by an orthopedic surgeon in 11 patients, a surgeon in 3, a pediatrician in 2, and a bonesetter in 1. The initial diagnosis was slipped capital femoral epiphysis in 5 patients, absence of abnormalities in 3, Perthes disease in 2, unknown in 2, and growing pain, transient synovitis of the hip, and femoral neck fracture in 1 each. At the time of the visit to our hospital, a correct diagnosis was soon made in all patients. The disease type was acute slip in 2 patients, chronic slip in 8, and acute on chronic slip in 6. Mild slip (between 0° and 30°) was observed in 10 patients, moderate slip (between 30° and 60°) in 5, and severe slip (>60°) in 1 (Fig. The mean interval between the onset of symptoms and the initial visit to the hos- pital was 69 days and that from the first visit to diagnosis was 30 days. The physique (height, weight) of the patients was compared with its distribution according to age reported by the School Health Statistic Survey in 2005. Compared Slipped Capital Femoral Epiphysis Retrospective 71 60 Mild slip Moderate slip Severe slip 50 10 cases 5 cases 1 cases 40 37 54 29 78 30 48 20 37 59 10 19 10 7 1214 18 23 20 0 8 0 30 60 Posterior tilting angle(degree) Fig. Relation between head-shaft angle and posterior tilting angle with the mean statistical values, the height of the patients was −10. Com- pared with the mean statistical values, the weight of the patients was −10. Endocrinological examination showed a low testosterone level in one patient. However, abnormalities could not be confirmed in any patient because they were in the growth stage. Surgery was performed in all patients; Southwick intertrochanteric osteotomy was performed in 5 patients and in situ pinning in 11. Contralateral preventive bone epiphyseal fixation was performed in all except 1 patient. The implant used for in situ pinning was the Knewles pin in 2 patients, Kirschner wire (k-wire) with thread in 3, and ACE(R) SCFE screw in 6. For contralateral preven- tive pinning, the Knewles pin was used in 2 patients, k-wire with thread in 3, ACE SCFE screw in 9, and Hannson pin in 1. For fixation after Southwick intertrochanteric osteotomy, the AO double angle plate (MIZUHO, Tokyo, Japan) was used. In all patients, epiphyseal fixation was added, and the implants used were the same materi- als as those used in preventive pinning. The flexion osteotomy angle was frequently 20°–30°, although it was 50° in 1 patient. Good reductions in both the posterior tilting angle and head–shaft angle were observed. Concerning surgical complications, methicillin-resistant Staphylococcus aureus infection associated with Southwick intertrochanteric osteotomy developed in one patient and k-wire breakage associated with in situ pinning in one. Leg length dis- crepancy after Southwick intertrochanteric osteotomy until the final observation was observed in three of five patients (0.

He who was desperately ill purchase viagra super active 25mg visa erectile dysfunction treatment in pune, emaciated and toxic from was born at a fortunate hour and took full advan- extensive active tuberculous disease of the left tage of the opportunities that were presented order viagra super active 50 mg without a prescription erectile dysfunction treatment cincinnati, lung with secondary pyogenic infection and turning all his talents to such development of abscess formation. The man recov- Macewen’s contributions were so varied and of ered his health completely and afterwards was such a quality that he must be regarded as one of actively engaged in earning his livelihood for the greatest surgeons of all time. In 1892 Macewen became Regius Professor of Surgery at Glasgow University, a post that entailed a good deal of teaching and transference of his surgical work to the Western Infirmary. He was also elected an Honorary Fellow of the Royal Colleges of Surgeons of England and of Ireland; several universities conferred honorary degrees upon him, and he received recognition from leading surgical societies abroad. Soon after the outbreak of war in 1914, he was commissioned as 212 Who’s Who in Orthopedics famous contributions are probably his studies on the pathogenesis of low-back pain, which led to a greater understanding of what many had pre- viously diagnosed as lumbago. He also had expertise in the areas of hallux rigidus, patellar dislocation, opponens transfer, whiplash injuries, pathological changes in the neurocentral joints of the cervical spine, lesions of the menisci, anterior tibial compartment syndrome, the effect on osteo- genesis of alternating currents in bone, blood supply of the vertebral bodies and the femoral head, the reaction of body tissues to ceramics, the microcirculation of the rotator cuff, and shoulder arthroplasty. He was awarded the Hunterian Lectureship of the Royal College of Surgeons of England for his studies on the rotator cuff. To North Ian MACNAB Americans, his knowledge and expertise, com- bined with his command of the English language 1921–1992 and his Churchillian oratory, made him one of the most sought-after orthopedic lecturers and visit- Ian Macnab was the son of a Scottish shipbuilder ing professors. When Ian was 5 years was exemplified in his classic Presidential old, his parents sent him home to Britain to Address, entitled “Seek and Ye Shall Find,” to the receive an education in an English boarding Canadian Orthopedic Association in 1977, in school. He attended medical school at the Uni- which he stated: “You do not have to be a trained versity of Birmingham, graduating with first-class investigator to discover. After a residency in general and orthope- serve your sense of wonder, your ability to be dic surgery, he served in the Royal Army Medical astonished and you must be sure that your brain Corps, from 1945 to 1947. He then completed remains connected to your retina so that you will his orthopedic training at the Royal National not only see, but you will also perceive.... More became interested in low-back disability and, at importantly, it is an attitude of mind. Every the recommendation of Sir Herbert Seddon, went surgeon must recognize his own potential in this to Toronto in 1950, to study the pathogenesis of regard and not be content to leave advances to low-back pain, as a research fellow at the Bunting others. As a testimonial and legacy to Ian’s outstand- Ian’s outstanding contributions as researcher, ing influence as a teacher and his ability to shape teacher, and orthopedic surgeon led to his being the lives of others, a dynamic group of 40 of his asked, by the Chairman of the University, Dr. Dewar, to establish a university which looked to Ian and his wife, Reta, as guiding orthopedic service at the Toronto General Hospi- patrons. Ian acquired a passionate devotion and pride uate fellows with Ian, are now located in 22 ortho- for his adopted country, for Toronto, and for its pedic centers and seven countries. A very close personal rela- Although Ian’s scientific contributions have tionship developed between Ian and Dr. Dewar made a lasting mark in orthopedics, for those who and his other Toronto colleagues. He was knew him personally his personal traits are what appointed Professor of Orthopedic Surgery at the will be most cherished. His warm friendship, University of Toronto and Chief of the Orthope- loyalty, tremendous sense of humor, ability to dic Service at the Wellesley Hospital. Although he was interna- teachings, in both the spoken and written word, tionally renowned as a spine surgeon, his most will be passed on by his friends, colleagues, 213 Who’s Who in Orthopedics fellows, and residents to future orthopedic sur- and after a period under house arrest he retired to geons as a viable continuation of his presence. Ian Macnab died on November 25,1992, at the Apart from his work on intestinal resections, Toronto General Hospital, after a brief illness. He intestinal typhoid, obstruction and so on, leaves behind his wife, who met Ian when she was Madelung was one of the first advocates of early a charge nurse in the orthopedic operating room laparotomy for abdominal injuries. In 1909 he at the Toronto General Hospital, and his three described arthrotomy of the shoulder from children. His description of deformity at the wrist was not original, and only a little more complete than descriptions by Dupuytren and R. It is difficult to give much impression of his personality—someone described him as a “serious and conscientious man with powerful will” and this rather stern picture is supported by one of his sayings: “Every clinical lesson must be prepared and conducted in such a way that every student who contemplates missing the class must feel that he would miss something important. Heavy work by young people produced more pressure on the anterior part of the distal radial epiphysis than the poste- rior part. In those with “primary weakness of bone” this degree of pressure may cause the ante- rior part of the epiphysis to stop growing. As a result, the lower end of the radius comes to be angulated forwards. However, Madelung Otto MADELUNG noted that the pin disappeared after time, even 1846–1926 when the subluxation was gross, and that the capacity for work was not impaired. Madelung was an abdominal surgeon—he flour- ished during the time that surgery was beginning to have something to offer the patient with abdominal disease.

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