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By Z. Riordian. Carnegie Institution of Washington.

Anecdotal information and chat rooms can be helpful in pointing you in a spe- cific direction; they should not be relied on for factual data 100mg viagra soft valsartan causes erectile dysfunction. Most health top- ics you might be searching for will have multiple rather than single studies generic viagra soft 100mg amex erectile dysfunction medication cheap. Be sure to read several studies on the same topic before taking the first one you find at face value. If several studies duplicate the same results, these results can probably be trusted. Medical Detective Work on the Internet 83 A single study could have turned out to be a dead end that no one continued to research, or it could be so new that the results haven’t yet been duplicated. So if it’s a single study, you can probably assume the results are not yet accepted by the scientific community. PubMed is a premier Internet site maintained by the National Library of Medicine and the National Center for Biotechnology Information. It allows public access to the NLM’s MEDLINE database, which houses articles from forty-five hundred journals from as far back as 1966. If you are unable to find a study mentioned there, the chances are better than not that the study was not published in a peer-reviewed journal. However, it is not essential for you to read the complete arti- cle or abstract. They (and you) need to read only the title and the conclusion section, which usu- ally contains short amounts of text. Possible Pitfalls in Internet Detective Work There are any number of problems in doing detective work on the Internet, which is why we always urge you to check the information you have found with your physician. Be careful of the following: E-Mailing a Physician Since it is difficult to understand the scientific language found in many med- ical articles, you can e-mail a physician on his or her website if this service is offered. But be aware that you may not receive an answer or you may get one that is not specific enough for you. Attorneys and malpractice insur- ance carriers have warned physicians about the amount of information they should give over the Internet. These physicians may be exposing themselves to liability, especially if the query is from someone who is not already one of their patients. The reason for this is because when a doctor responds to specific ques- tions, he or she creates a doctor-patient relationship. The physician now has a duty to this patient regardless of whether or not the patient has been seen personally in an office and regardless of whether or not monies have been exchanged. Keeping this in mind, you are highly unlikely to receive much help from e-mailing a physician or website for specific information about your particular condition. Remember, one of the qualities you examined in choosing your doctor (see Chapter 4) was your comfort level in bringing new information to him or her, so this a good time to exercise that prerogative. However, rare as it may be, you might get lucky using Internet con- sultation. For example, Steve, a forty-five-year-old independent contractor who was self-employed, thought that he was having chest pain from heart disease. He was afraid to go to the doctor because he didn’t have insurance to cover the office visit and expensive tests the doctor would probably want to order. By using the Internet, Steve was able to communicate his symp- toms to a physician at allexperts. The physician was able to diagnose that his problem was from heartburn, and Steve’s condition was successfully treated with over-the-counter medication. Using Pharmaceutical Sites The websites of drug manufacturers can sometimes be a good source of information in the same way as the Physician’s Desk Reference (an annual compilation of information on and descriptions of prescription medications currently available). Although these sites appear professional and do con- tain a lot of information about the particular drugs the companies manu- facture, you must bear in mind that they have an ultimate goal—selling their drugs. That goal does not necessarily include providing you with compar- isons or a full study of the drugs. One group from the University of Iowa College of Medicine confirmed this by reviewing the material found on the websites of nine pharmaceutical companies that manufacture medication to treat depression.

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Muscle Weakness • Quality and Character: I feel like a straw doll but have no aches or pains that go with it effective viagra soft 100mg erectile dysfunction and diabetes type 2. That’s when I started gaining weight buy viagra soft 50mg low cost impotence natural home remedies, so I began eating less; exercising more; and taking soy products, eve- ning primrose oil, and other food supplements. Exercise used to give me more energy; now my weakness is persistent and nothing makes 154 Diagnosing Your Mystery Malady it better although exercising now can make it worse. Step Four: Do a Family Medical History and Determine If You Have or Had Any Blood Relatives with a Similar Problem. My father died of colon cancer at the age of seventy-one, but he was heavy and never took care of himself. My mother’s brother also had cancer, and my mother had skin can- cer from which she ultimately died. My sisters are living and generally healthy, although my elder sister is obese like my father and has high blood pressure. Step Five: Search for Other Past or Present Mental or Physical Problems. In the past, I considered myself a healthy person but never felt better than when I started working out. After my last child left for school, I was treated for depression with Prozac. Step Six: Categorize Your Current and Prior Significant Medical Problems by Etiology. I used to think my worth was about being a mom so when my last child left home, I felt lost. Going to the clubs on South Beach and having younger men act interested in me also helped me feel good about myself. Don’t get me wrong; I have always been happy with Burt and love him dearly. I knew he wasn’t happy about what I was doing, but it felt like something I needed to do for myself. I went from fit and trim to feeling haggard and even having muscle weakness and spasms like an old person. I didn’t want to acknowledge this because I was afraid I might have cancer like my mother and father or just be dying—and maybe I might or should be if I am just going to be fat, weak, and old. Step Eight: Take Your Notebook to Your Physician and Get a Complete Exam. Rosenbaum gave Maria a thorough physical exam after his nurse reported to him that his patient was so weak she had difficulty get- ting up on the scale to be weighed. Rosenbaum did his own laboratory testing because different lab- oratories sometimes yield different results. He too found elevated muscle enzymes indicative of muscle inflammation as well as a dangerously low potassium level. In fact, it was low enough to cause electrocardiogram (EKG) abnormalities. Rosenbaum did was to encourage Maria to begin eating foods rich in potassium and take potassium supplements. There was no identifiable medical condition that could explain what was going on with her. Maria’s journal revealed her fear of becoming overweight and meno- pausal and how strong her feelings were regarding this subject. Rosenbaum suspect that diuretics, or “water pills,” were playing a role in Maria’s mys- tery malady. These medications increase the volume of urine formation, helping the body to decrease excess fluid. Unfortunately, they can also “wash out” essential minerals and electrolytes like potassium and cause muscle spas- 156 Diagnosing Your Mystery Malady ming and weakness along with an elevation in muscle enzymes.

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Organs sensitive to anoxia generic viagra soft 50mg line erectile dysfunction medication costs, such as the brain and kidney discount viagra soft 50mg fast delivery erectile dysfunction pumps review, may be severely damaged before the heart stops. In such cases cardiopulmonary resuscitation (CPR) may restore cardiac output but the child will still die from multisystem failure in the ensuing days, or the child may survive with serious neurological Stimulate and check responsiveness or systemic organ damage. Therefore, the early recognition of the potential for cardiac arrest, the prevention and limitation Open airway. Head tilt, chin lift (jaw thrust) of serious injury, and earlier recognition of severe illness is clearly a more effective approach in children. Two effective breathes If no chest rise Paediatric basic life support - reposition airway - re-attempt up to five times Early diagnosis and aggressive treatment of respiratory or Assess for signs of a circulation If no success cardiac insufficiency, aimed at avoiding cardiac arrest, are the Yes Check pulse (10 seconds maximum) - treat as for airway obstruction keys to improving survival without neurological deficit in No seriously ill children. Five compressions: oxygenation are the most important actions in paediatric One ventilation, 100 compressions/minute resuscitation. Continue resuscitation Resuscitation should begin immediately without waiting for the arrival of equipment. This is essential in infants and Algorithm for paediatric basic life support children because clearing the airway may be all that is required. Assessment and treatment should proceed simultaneously to avoid losing vital time. As in any resuscitation event, the Airway-Breathing-Circulation sequence is the most appropriate. If aspiration of a foreign body is strongly suspected, because of sudden onset of severe obstruction of the upper airway, the steps outlined in the section on choking should be taken immediately. Assess responsiveness Determine responsiveness by carefully stimulating the child. Care must be taken not to overextend the neck (as this may cause the soft trachea to kink and obstruct) and not to press on the soft tissues in the floor of the mouth. Pressure in this area will force the tongue into the airway and cause obstruction. The small infant is an obligatory nose breather so the patency of the nasal passages must be checked and maintained. Alternatively, the jaw thrust manoeuvre can be used when a Opening infant airway 43 ABC of Resuscitation history of trauma or damage to the cervical spine is suspected. Maintaining the paediatric airway is a matter of trying various positions until the most satisfactory one is found. Breathing Assess breathing for 10 seconds while keeping the airway open by: ● Looking for chest and abdominal movement ● Listening at the mouth and nose for breath sounds ● Feeling for expired air movement with your cheek. If the child’s chest and abdomen are moving but no air can be heard or felt, the airway is obstructed. If the child is not breathing, expired air resuscitation must be started immediately. With the airway held open, the rescuer covers the child’s mouth (or mouth and nose for an infant) with their mouth and breathes out gently into the child until the chest is seen to rise. Minimise gastric distension by optimising the Mouth-to-mouth and nose ventilation alignment of the airway and giving slow and steady inflations. Up to five attempts may be made to achieve two effective breaths when the chest is seen to rise and fall. Circulation Recent evidence has questioned the reliability of using a pulse check to determine whether effective circulation is present. Therefore, the rescuer should observe the child for 10 seconds for “signs of a circulation. In addition, healthcare providers are expected to check for the presence, rate, and volume of the pulse. The brachial pulse is easiest to feel in infants, whereas for children use the carotid pulse. If none of the signs of a circulation have been detected, then start chest compressions without further delay and combine with ventilation. Immediate chest compressions, combined with ventilation, will also be indicated when a healthcare provider detects a pulse rate lower than 60beats/min. In infants and children the heart lies under the lower third of the sternum. In infants, compress the lower third of the sternum with two fingers of one hand; the upper finger should be one finger’s breadth below an imaginary line joining the nipples. When more than one healthcare provider is present, the two-thumbed (chest encirclement) method of chest compression can be used for infants.

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Bartholomew’s buy discount viagra soft 50mg online erectile dysfunction medications causing, extensive use was made of chief order viagra soft 50mg without a prescription erectile dysfunction doctor san diego, they do most probably imply an effusion of a escharotics and the actual cautery, but Pott con- fluid somewhere; this effusion may be in the substance demned the practice and ultimately succeeded in of the brain, in its ventricles, between its membranes, abolishing it. Furthermore, he contrived to render or on the surface of the dura mater; and which of these surgical treatment as mild as possible, consistent is the real situation of such extravasation is a matter of with efficiency; and this principle was reflected in great uncertainty; none of them being attended with any his use at operations of a reduced number of peculiar mark, or sign that can be depended upon, as pointing it out precisely; but the inflammation of the instruments of simple design. These reforms were dura mater, and the formation of matter between it and greeted with some contempt by his colleagues the skull, in consequence of contusion, is generally who were accustomed to elaboration of technique indicated and preceded by one which I have hardly ever but Abernethy, a warm admirer, testified to Pott’s known to fail; I mean a puffy, circumscribed, indolent consideration for the ease and comfort of his tumour of the scalp, and a spontaneous separation of patients. He also had a kindly heart toward his dressers, These appearances therefore following a smart blow on some of whom he took into his own home. He the head, and attended with languor, pain, restlessness, took a leading part in improving the instruction of watching, quick pulse, headache, and slight irregular students. His lectures were open to all on payment shiverings, do almost infallibly indicate an inflamed dura mater, and pus, either forming or formed between of a small fee and they were well attended. His monograph on palsy of the lower injuries did much to establish him as one of the leading surgeons of his day. One instance is Judging by portraits of Pott, he had a pleasing chimney-sweep’s cancer, which he was the first to appearance, and dressed according to the fashion describe; he was the first to point out the car- of the period, visiting the hospital in his powdered cinogenic properties of soot on man. In the words of mental verification of Pott’s observations on the Earle he was “elegant, lower than middle size. He was a devoted the misery of the chimney-boys, he drew the son, and made a home for his mother until her attention of profession and public to the evil death in 1746, after which he married the daugh- nature of their occupation: ter of Robert Cruttenden, by whom he had five sons and four daughters. In 1769 he bought a The fate of these people seems singularly hard; in house near Lincoln’s Inn Fields and resided in it their early infancy, they are most frequently treated with great brutality and almost starved with cold and for 7 years, when he moved to Prince’s Street, hunger; they are thrust up narrow and sometimes hot Hanover Square. At this time Sir Caesar Hawkins, chimneys where they are bruised, burned and almost who was reputed to have the best surgical prac- suffocated; and even when they get to puberty become tice in London, retired and Pott succeeded him in peculiarly liable to a most noisome, painful and fatal professional favor. For the next 10 years, Pott was much in demand as a consultant and, apart from his hos- The employment of chimney-boys was eventu- pital work, he kept up a large correspondence ally made illegal by Act of Parliament. It is almost with surgeons and practitioners who sought his incredible that even today there should exist a link opinion and advice from all over the world. He 277 Who’s Who in Orthopedics was the recipient of many distinctions: in 1764 he References was elected a Fellow of the Royal Society; the next year he was appointed Master of the Corpo- 1. Bartholomew’s Hospital Reports 30:163 first Honorary Fellow of the Royal College of 2. Lloyd, G Marner (1933) Life and Works of Perci- Surgeons of Edinburgh and the year after that an vall Pott. Bartholomew’s Hospital Reports 66:291 Honorary Member of the Royal College of Sur- 3. These last two honors were con- Percivall Pott, FRS, to which are added “A short ferred upon him at about the time of his retirement Account of the Life of the Author,” by James Earle, from St. Power, Sir D’Arcy (1923) Percivall Pott: His own boy for half a century. Power, Sir D’Arcy (1929) The Works of Percivall the hospital subscribers, he was elected a gover- Pott. British Journal of Surgery 17:1 nor and at dinner that followed there was a moving scene. The Right Honorable Thomas Harley proposed the toast of Percivall Pott, who was usually composed and eloquent, but on this occasion was overcome with such emotion that, after rising to reply, was unable to speak and resumed his seat in silence. He continued to practice, but his retirement lasted only about 18 months. On December 27, 1788, he died of pneumonia due to a chill he caught while visiting a patient in severe weather 20 miles from London. His last conscious words were: “My lamp is almost extinguished; I hope it has burnt for the benefit of others. Percivall Pott was a great leader in surgery who shone as a clinical surgeon. He flourished before the emergence of surgical pathology under John Hunter, and the deductions from his clinical observation suffered from this lack of scientific interpretation. He was, however, particularly free Kenneth Hampden PRIDIE from the shackles of tradition and was bold enough to cut a path of his own. In a sense he 1906–1963 was more acquainted with the practice of surgery than Hunter but he lacked, as they all lacked Born in Bristol, educated at Clifton College and before the coming of Pasteur and Lister, the the University of Bristol, Ken was a true son of one key that saved surgery from being a tragic that ancient city, in which he spent his whole life adventure. He took part in the an impressive personality, a character in the best formation of the Corporation of Surgeons and sense of the term, and his life and work depict the became its Master, started organized teaching of originality of his mind.

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