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Associate Professor, Florida State University College of Medicine

Recent NHS reforms in Britain are pushing doctors both to play a wider role in regulating the behaviour of their patients and to ration the allocation of resources to patient care cholesterol quizlet gemfibrozil 300mg sale. But people need less nannying when they are well and more health care when they are ill cholesterol vs fat buy cheap gemfibrozil. Michael Fitzpatrick concludes that doctors should stop trying to make people virtuous cholesterol levels should be generic gemfibrozil 300mg without prescription. He argues that we need to establish a clear boundary between the worlds of medicine and politics, so that doctors can concentrate on treating the sick—and leave the well alone. Michael Fitzpatrick is a General Practitioner working in Hackney, London. CONTENTS Preface vii Glossary of acronyms xii 1 Introduction 1 2 Health scares and moral panics 13 3 The regulation of lifestyle 35 4 Screening 55 5 The politics of health promotion 72 6 The expansion of health 96 7 The personal is the medical 118 8 The crisis of modern medicine 130 9 Conclusion 155 Bibliography 174 Index 188 v PREFACE On a bitterly cold February day in the winter of 1987 I had to break into the house of an elderly couple who had succumbed to a combination of infection and hypothermia. While I waited for the ambulance I found, unopened on the doormat, a copy of the government’s ‘Don’t Die of Ignorance’ leaflet which had been distributed to twenty-three million households as part of the campaign to alert the nation to the danger of Aids. Around half of these households contained either an old couple or an old person living alone. What was striking about the ‘worried well’ was not only the intensity of their anxiety about a rare disease that they had little chance of contracting, but the effect of the Aids publicity in making them question the way they conducted their personal life. Whether or not they were at risk of HIV, the Aids campaign put people under real pressure to conform to official guidelines regarding their most intimate relationships. The more I examined the Aids campaign the less it seemed to be a rational response to a new disease, and the more it seemed to be about the promotion of a new code of sexual behaviour. Not only were fears being needlessly inflamed, but this was being done to establish new norms of acceptable and appropriate behaviour. It was also supplemented by a systematic government drive to change personal behaviour in areas such as smoking, alcohol, diet and exercise through the 1992 Health of the Nation initiative, and by the promotion of mass cancer screening programmes targeted at women (cervical smears and mammograms). To an unprecedented degree, health became politicised at a time when the world of politics was itself undergoing a dramatic transformation. The end of the Cold War marked an end to the polarisations between East and West, labour and capital, left and right, that had dominated society for 150 years. The unchallenged ascendancy of the market meant that the scope for politics was increasingly restricted. Collective solutions to social problems had been discredited and there was a general disillusionment with ‘grand narratives’. One indication of the resulting ideological and political flux was the fact that the remnants of the left broadly endorsed the Conservative government’s Aids campaign (some criticising it for not going far enough), while some right-wingers challenged its scaremongering character (though a few hardliners demanded a more traditional anti- gay, anti-sex line). As someone who had always identified with the political left, the ending of the old order in the late 1980s led to some contradictory and disconcerting developments. In response to a series of setbacks at home and abroad, the left lowered its horizons and became increasingly moderate and defensive. The weakness of the British left had always been its tendency to confuse state intervention for socialism. In the past, however, the state had intervened in industry and services; now (as it tried to retreat from some of its earlier commitments) it stepped up its interference in personal and family life. The left’s endorsement of the government’s Aids campaign, following earlier feminist approval of the mass removal of children from parents suspected of sexual abuse in Cleveland, signalled the radical movement’s abandonment of its traditional principles of liberty and opposition to state coercion. While most conservative commentators loyally defended government policy, only a small group of free-market radicals was prepared to advance a, rather limited, defence of individual freedom against the authoritarian dynamic revealed in the government’s health policies (see Chapter 5). Until the early 1990s, politics and medical practice were distinct and separate spheres. Some doctors were politically active, but they viii PREFACE conducted these activities in parties, campaigns and organisations independent of their clinical work. No doubt, their political outlook influenced their style of practice, but most patients would have scarcely been aware of where to place their doctor on the political spectrum. Systematic government interference in health care has since eroded the boundary between politics and medicine, substantially changing the content of medical practice and creating new divisions among doctors.

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At the end of the service of the Royal Air Force cholesterol lowering through diet gemfibrozil 300 mg visa, what still stands week cholesterol levels that require medication 300mg gemfibrozil free shipping, R cholesterol medication symptoms order gemfibrozil online from canada. Each paper tal to organize an orthopedic and accident depart- had to be word perfect, we were to speak to the ment and become its director. To this he brought back row, adhere strictly to the time allocated, and the same qualities of drive, enthusiasm and com- have illustrations of the highest standard. When I left the Royal Air Force in 1946, attention to detail characterized so much of what he insisted on my applying for a consultant post he did. Alexander Law, a superb Memorial Hospital, and it was typical that his department was built up much along the RAF acceptance was conditional on the allocation of lines, in which the four of us worked in great hap- one of the local practitioners exclusively to the piness and rapport until he and I retired from the management of fractures. In the same year he National Health Service within a year or two of joined the consultant staff of the Shropshire each other. Orthopedic Hospital at Oswestry, where he He was a wonderful colleague, inspiring and became the chief of the North Wales firm. I suc- dedicated to the task of the present; I always ceeded him in both these commitments. After- 351 Who’s Who in Orthopedics care clinics held in chapels, schools and cottage failing health, he journeyed to the Eryri Hospital hospitals throughout North Wales took him far at Caernarvon. He enjoyed recalling that on one of these remember how keen and sharp his mind was, and visits to Blaenau Ffestiniog, he ran into and killed how clear the message. Later on this occasion he a horse: it was an insignificant cob that crossed was struck down by his last illness, and it was a the road that day without looking both ways, but privilege to be able to repay a very small part of by the end of the litigation that followed it had a long-standing debt. His powerful teaching was often uncompromising and strongly held beliefs Sir Reginald first came to Oswestry in 1928 as were always communicated with conviction; he assistant surgeon to David Macrae Aitken, barely believed passionately. Many a young Oswestrian 4 years after qualification, having already estab- suffered painful knuckles in the process of learn- lished his reputation in Liverpool as a young ing the “no-touch” technique. Less widely fell in love with “The Orthopedic” and this was accepted beliefs were his obsessions about anky- returned in no small measure over the years. He losing spondylitis, physiotherapy and the value of loved the Welsh border county. Indeed it was in a crooked and elongated heels in the treatment of small cottage in Shropshire that he took refuge genu valgum. His old friend, incomplete immobilization, plasters in equinus or John Menzies, recalls those mammoth writing the use of abbreviations in case notes. His dark, sessions interspersed with bridge, music and penetrating, alert eyes and warm personality pro- asparagus. In the late 1920s he pioneered the periph- listened sympathetically to the views of young eral clinics in Wrexham and North Wales in the residents but towards the end of his career best traditions of Robert Jones, and attended R. Llangwyfan Hospital in the Vale of Clydd with He will be remembered by many an adminis- the late Arthur Rocyn Jones, at a time when bone trator and some of his senior colleagues for his and joint tuberculosis was rife in the Welsh coun- midnight telephone calls, by nurses and doctors tryside. He became a household name: his friend- of all ranks alike for his identification with the liness to patients of all ranks, his love of children social life of the hospital. He introduced many of and his personal magnetism proved irresistable to the established traditions of the Oswestry doctors’ his Celtic patients. They adored him, as did all mess, notably “Roll the Red,” a peculiar game grades of staff in the hospital community. Generations of residency are a permanent reminder of his young orthopedic surgeons trained at Oswestry generosity. When ultimately the time for legion, Oswestry remained his spiritual home. As retirement arrived in March 1967, he refused to senior surgeon, his advice and support were freely admit it and nobody dared to refer to his retire- available, locally and in high places. He loved senior adviser in postgraduate studies for some Oswestry dearly, and his last clinical activity was years and was instrumental, with others, in found- with his colleagues in the Welsh firm, when, in ing the Charles Salt Research Institute. In 1952 352 Who’s Who in Orthopedics he was elected founder president of the Old World War when students were few. He won an Oswestrians Club and delivered the Gold Medal entrance scholarship to King’s College Hospital lecture in 1970. He faithfully supported the in London, where he did the clinical part of his hospital League of Friends from its inception in medical studies, graduating in 1945 and being 1961, and his radio appeal for funds in 1964 will awarded the Legg prize in surgery. He sub- be remembered as a masterpiece of oratory and sequently worked as resident medical officer and cajolery.

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However cholesterol levels lab values buy gemfibrozil 300mg without prescription, most of the results published to date relate to resurfacing in a population essentially composed of patients treated for idiopathic or “primary” OA cholesterol score of 5.3 buy gemfibrozil 300 mg otc. In Asia cholesterol in foods list cost of gemfibrozil, primary OA is extremely rare [25,26], and hip arthroplasty essentially applies to degenerative changes secondary to developmental dysplasia of the hip (DDH), osteonecrosis (ON), posttrauma (PT), slipped capital femoral epiphysis (SCFE), Legg–Calve–Perthes (LCP) disease, and inflammatory diseases (rheumatoid arthritis, etc. The purpose of the present study was to review the indications and assess the clini- cal results of a current metal-on-metal hip resurfacing design in a population of patients treated for nonprimary OA. Materials and Methods From a series of more than 950 hips treated with metal-on-metal hybrid resurfacing (Conserve Plus; Wright Medical Technology, Arlington, TN, USA), 208 patients (238 hips) underwent the procedure between November 1996 and June 2005 for a diagnosis other than primary OA. The degeneration of the articular cartilage was secondary to DDH in 82 hips (34. The surgical technique employed in this series has been described in detail in previous publica- tions [28–30], and the effects of the modifications made from the initial surgical technique have been evaluated. The patients were evaluated preoperatively, immediately after surgery, at 3 to 4 months, at 1 year, and then at yearly intervals. Radiographic data consisting of a low anteroposterior pelvis view, a modified table down-lateral, and a Johnson lateral view were collected at each visit. The radiographic analysis was similar to that reported in our previous publications. The clinical outcome of the surgeries was evaluated pre- and postoperatively using the University of California at Los Angeles (UCLA) hip scoring system and the Short-Form 12 questionnaire (SF-12). The Harris hip score was calculated postoperatively as an overall assessment of success comparable to other studies. The Surface Arthroplasty Risk Index (SARI) was calculated for each hip to evaluate the suitability of the group to be treated with a resurfacing procedure. A statistical analysis was performed using Kaplan–Maier survivorship curves and log-rank tests for comparison of survivorship data. Paired Student’s t tests were used for comparison of preoperative to postoperative clinical scores, and two-sample equal-variance t tests were used for comparisons of clinical scores with other groups of patients. Only one of these was associ- ated with clinical symptoms of loosening in a patient who was lost to follow-up. A narrowing of the femoral neck of 10% or more at the junction with the femoral component was observed in ten hips, but no definite association could be made with femoral component failure. Clinical scores of the study group (pre- and postoperative) and in comparison with patients operated for primary osteoarthritis (OA) Study group, P Study group, P Primary OA, preoperative postoperative postoperative UCLA hip scores Pain 3. Seven-year-postoperative radiograph of a 40 year-old woman who underwent metal- on-metal resurfacing for developmental dys- plasia of the hip (DDH). The region of interest highlights a radiolucency, which has been visible around the metaphyseal stem for more than 6 years, indicating imperfect initial fixa- tion with first-generation cementing technique (cyst size was 2cm). The patient has no clinical symptoms, indicating a degree of stability commensurate at this time with her activity level of 7 and her weight of 67kg Complications There were a total of 14 complications (overall rate, 5. One hematogenous sepsis happened 10 days after surgery and was treated with soft tissue debridement and antibiotics. One of 5 patients operated through a lateral transtrochanteric approach developed a trochanteric bursitis, which resolved with the removal of wires used in the reattachment of the greater trochanter. Metal-on-Metal Resurfacing 199 A component size mismatch that occurred early in the series before prepackaging of the components was resolved with replacement of the acetabular shell with a 2-mm-thicker custom component of the appropriate inner diameter. One hip required a reexploration to remove residual bone cement trapped in the joint after hip reduc- tion. Finally, one hip needed acetabular reconstruction after the acetabular shell protruded through the acetabular wall. The patient was heavy, had poor bone quality, and had undergone simultaneous bilateral resurfacing (the event occurred on the first hip operated). In addition, the wall had presumably been further weakened by overreaming. Conversions to THR Thirteen hips were converted to a THR in this series. The reasons for revision included 2 for fracture of the femoral neck, 9 (in 8 patients) for femoral component loosening, 1 for late hematogenous sepsis, and 1 for recurrent subluxation secondary to ischial– trochanteric impingement. The femoral neck fractures occurred at 2 and 5 months after surgery (both with a diagnosis of DDH in patients with poor bone quality), and the loosening of the femoral component occurred at an average of 53.

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Cases of dysplastic hip cholesterol test error order generic gemfibrozil pills, Crowe III and IV less cholesterol in eggs purchase gemfibrozil once a day, treated with enlargement in 1987 to 2003 Limb shortening (preoperative): 20–70mm (mean: 44 quitting cholesterol medication gemfibrozil 300mg line. Complications in cases of dysplastic hip, Crowe III and IV, treated with enlargement in 1987 to 2003 Nerve palsy: 12 cases Peroneal nerve: 7 cases 5: fully recovered; 2: paraesthesia) Femoral nerve: 5 cases (all fully recovered) Dislocation: 7 cases Closed reduction: 4 cases Open reduction: 1 case Converted to consrained type: 2 cases Loosening: 9 cases Acetabular side: 8 cases Bipolar → cementless THR: 2 cases (within 3 years postoperative) Cementless THR: 6 cases Larger cementless: 4 cases Supportring cementless: 2 cases Femur side: Revision to cementless stem: 1 case THA for High Congenital Hip Dislocation 235 procedure. In 4 cases, closed reduction was performed under intravenous anesthesia and no further episodes were observed. In 1 case, an open reduction was necessary and no further episodes were seen. Because of the recurrent dislocations, it was necessary to convert to the constrained-type prosthesis in 2 cases. Among 6 cases of cementless total hip arthroplasty, 4 cases were revised by using the larger cementless cups and 2 cases had to be revised by using the cup supporter with bone cement. One case of femoral side loosening was revised by using the cementless type of revision prosthesis. Discussion In patients with poor acetabular bone stock, superior coverage of the acetabulum can be achieved by performing a horizontal osteotomy at the margin of the acetabulum, or by femoral head grafting as proposed by Harris et al. However, these techniques cannot improve anteroposterior bone deficiency, and extensive reaming of the acetabulum may lead to additional bone loss of anteroposterior osseous support. Furthermore, it is not possible to remedy the thin femur and narrow femoral med- ullary canal solely with bone grafting. For treating a narrow medullary canal, the use of a narrow stem has been described by Charnley and Feagin, Buchholz et al. However, using a small component for the acetabulum or the femur has a greater risk of breakage or loosening. Therefore, the surgical methods described above were developed for the purpose of enlarging both acetabulum and femoral medullary canal. These methods permit inserting a normal-sized compo- nents into a small original acetabulum and into a narrow femoral canal without further wear of the bone stock. Our first choice was a cementless bipolar-type prosthesis for patients in their forties. It is safer to use the multiholed metal outer shell and its screws to stabilize the shell, while at the same time stabilizing the osteotomized portion. After this experience, we decided the component for the acetabular side should be a multiholed metal cup. To bring down the femur, which is necessary to implant the acetabular cup into the original true acetabulum, both the one-stage procedure (Kinoshita and Harana; Kuroki et al. According to these authors, to adjust down the femur sufficiently and to enclose a gentle reduction, the two-stage procedure is employed for patients who require lengthening of more than 3cm. Figure 18 shows the relation- ship between the distance of adjusting down and paralysis in our cases. Because of this experi- ence, we decided that the limit of adjusting down for the first stage should be less than 2. When the surgery is divided into two stages, an acetabular cup is placed in the first stage and the soft tissue release is done. The adjusting is then performed while the patient is conscious to check for paralysis. Relationship between the distance pulled down and paralysis 8080 7070 6060 5050 4040 3030 2020 1010 paralysis (paralysis ( )) paralysis (paralysis ( )) Pulling down of the femur could be done quantitatively by using an external fixator. After the femur is pulled down to the level of the original acetabulum, the femoral prosthesis is implanted in the second stage and the joint is reduced. To avoid intra- operative nerve damage under anesthesia, monitoring of the spinal cord potential (SCP) is recommended. At each step of the operative procedure, the shape and the height of the SCP waves are checked. If there is no change in the waves, the surgery is advanced to the next step. Patient 4 A 61-year-old woman with right side high dislocation, Crowe group IV, is shown in Fig. In general, not all patients with high dislocation of the hip joint require treatment with the method reported in this chapter. When, on the basis of preoperative CT scans, the original acetabulum and the femur are estimated to be narrow for normal- sized components and when the volume of the surrounding bone stock remaining after reaming is judged to be insufficient, this technique is utilized.

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