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Furthermore spasms after hemorrhoidectomy cost of azathioprine, the three-dimensional structure usually display a spectrum of susceptibilities to antibiotics muscle relaxant clonazepam purchase azathioprine on line amex, of this adhesion is similar to that of adhesins from other bac- with some antibiotics being very effective and others totally teria spasms spanish 50mg azathioprine with mastercard. For another bacterial species, the pattern of antibi- protective effect against the adhesion of other bacteria. Thus, for diag- In the case of the capsule-mediated adhesion, such as nosis of an infection and for clinical decisions regarding the the example above, capsular antibodies may also thwart adhe- best treatment, tests of an organism’s response to antibiotics sion. A standard method of testing for antibiotic resistance For microorganisms that secrete their own receptor, involves growth of the target bacteria in the presence of vari- such as Escherichia coli, or which have receptor molecules ous concentrations of the antibiotic of interest. Typically, this protruding from their own surface (an example is the hemag- test is performed in a specially designed plastic dish that can glutinin protein on the surface of Bordetella pertussis), adhe- be filled with agar (a Petri plate). Contamination of the agar, sion could be eliminated by blocking the manufacture or the which would spoil the test results, is guaranteed by the steril- release of the receptor molecule. The type of agar used is essential for the validity of the a vaccine to the adhesin target of Escherichia coli O157:H7. This pathogen, which can be permanently debilitating and The hardened agar surface receives a suspension of the even lethal to humans who ingest contaminated food or water, test bacteria, which is then spread out evenly over the surface often lives in the intestinal tracts of cattle. The intention is to form a so-called lawn of organ- adhesion of the bacteria, they could be “flushed” out of the isms as growth occurs. Thus, a vital reservoir of infection would have been absorbent material. The vaccine could be ready for the market by as Each disc has been soaked in a known and different concen- early as 2003. Another anti-adhesion strategy is to out-compete the As growth of the bacteria occurs, antibiotic diffuses out target bacteria for the available spots on the surface. If the concentration of the antibi- approach has been successful in preventing bacterial vaginal otic is lethal, no growth of the bacteria will occur. Suppositories loaded with bacteria called diffusing antibiotic will be below lethal concentration, so that Lactobacillus are administered. The result is a ring of no growth wall by the Lactobacillus can retard or even prevent the sub- around a disc. From comparison with known standards, the sequent colonization of the wall by a harmful type of bacteria. A myriad of compounds are available that antimicrobial compounds into the implant material, and with will fluoresce under illumination of specific wavelengths. In the case of antimicrobial Among the uses for the fluorescent compounds is the viability 23 Antibiotics WORLD OF MICROBIOLOGY AND IMMUNOLOGY Antibiotic susceptible and resistant strains of Stapylococcus. Controls need to be included to verify that the the presence of acridine orange, while dead bacteria will not. Often, identification of the The ability of living bacteria to fluoresce can also be bacteria will suggest, from previous documented tests of oth- exploited by another machine called a flow cytometer. This provides an almost “real-time” assessment of the proportion of a popula- AAntibioticsNTIBIOTICS tion that has been killed by an antibiotic. Antibiotics are natural or synthetic compounds that kill bacte- All the assessments of antibiotic effectiveness need to ria. There are a myriad of different antibiotics that act on dif- be done in a controlled manner. This necessitates the use of ferent structural or biochemical components of bacteria. The concentration the 1930s, there were few effective ways of combating bacte- of the bacteria used is also important. Illnesses such as pneumonia, tuberculosis, and “dilute” out the antibiotic, producing a false indication of typhoid fever were virtually untreatable, and minor bacterial 24 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Antibody-antigen, biochemical and molecular reactions infections could blossom into life-threatening maladies. In the decades following the discovery of penicillin, many naturally occurring antibiotics were discovered and still more were syn- thesized towards specific targets on or in bacteria. Antibiotics are manufactured by bacteria and various eukaryotic organisms, such as plants, usually to protect the organism from attack by other bacteria. The discovery of these compounds involves screening samples against bacteria for an inhibition in growth of the bacteria. In commercial settings, such screening has been automated so that thousands of sam- ples can be processed each day. Antibiotics can also be manu- factured by tailoring a compound to hone in on a selected target.

The early years of this institute for crippled children were not noteworthy muscle relaxant carisoprodol cheap azathioprine 50 mg with mastercard, until Alessandro Codivilla knee spasms causes buy 50mg azathioprine overnight delivery, modest and skillful master back spasms 6 weeks pregnant purchase azathioprine 50mg line, became its director and surgeon-in-chief. This great general surgeon, after excelling in the surgery of the gastrointestinal tract and the brain, devoted his talents to orthopedic surgery, and the “Istituto” became world-famous. Codivilla made original and important contributions to the surgery of frac- tures and the methods of tendon transplantation, and to the development and standing of the specialty. At his death in 1912, Codivilla was succeeded by Vittorio Putti, the son of a well-known surgeon who was for many years professor of surgery in the University of Bologna. Putti had first become identified with the Istituto Ortopedico Rizzoli in 1903, when Codivilla had appointed him as an Vittorio PUTTI assistant. Following 2 years of study in European 1880–1940 clinics, he returned to the institution in 1909 as vice director, and in 1914 became director and Vittorio Putti was professor in the University surgeon-in-chief of the Istituto. He was also of Bologna, surgeon-in-chief of the Istituto professor of orthopedic surgery at the University Ortopedico Rizzoli, a founder of the Société of Bologna. Internationale de Chirurgie Orthopédique et In 1922 he opened the country branch, which de Traumatologie and president of its 1936 provided for the care of 100 cases of surgical Congress, Honorary Member of the British tuberculosis, and as director of this hospital (Isti- Orthopedic Association, the American Orthope- tuto dio terapico Codivilla di Corona d’Ampezzo) dic Association, Corresponding Member of the in the Dolomites, he found frequent escape from American Academy of Orthopedic Surgeons, and his very strenuous city life. He was a bib- A brilliant student, a wide reader, an able liographer, medical historian, orthopedic investi- administrator, a resourceful and skillful surgeon gator, and teacher of surgeons. He had been a with a mechanical bent, he enhanced the 283 Who’s Who in Orthopedics reputation of the Istituto Rizzoli, and like Surgeons held in Boston in 1934 and in Chicago Codivilla, made lasting contributions to the in 1937. He received medicine and the contributory sciences, to strive from the King the title of Grand Officiali of the for exactitude in thought and action, and to appre- Crown of Italy. His sanctum sanctorum, which he cians and surgeons throughout the world and was shared with his helpers, was the library (La Bib- an inspiration to them. On the walls of this dignified discovered a depth of feeling and a capacity for room are the same beautiful frescoes, executed by friendship that were the true attributes of his char- Canuti, that had given joy to the monks, and on acter. After the death of his professional ideal, Sir its shelves are books and manuscripts covering a Robert Jones, he wrote the following letter in period of over 400 years. Its exquisite By his numerous original contributions he diction suggests a faith and an affection that are became an international leader, a pioneer and an almost religious in nature. It is a forcible manipulation of adult club feet, the open great friend who has left us, and I think that all of us treatment of fractures and the use of skeletal trac- who loved him feel the need of uniting together in his memory. Let our friendship find in his memory tion and metal fixation, the equalization of leg strength of faith and reason of comfort. Do not forget lengths by bone lengthening, spinal anomalies, me and believe me cineplastic amputations and artificial limbs, and Affectionately yours, the surgical treatment of the residual effects of PUTTI poliomyelitis. He published many monographs, not only on strictly medical and surgical subjects, Vittorio Putti will rank among the great ortho- but also on nonmedical subjects; as well as trans- pedic surgeons of all time—great in heart as well lations of old medical works. His latest volume, pub- lished in 1940, is entitled “Cura operatoria delle fratture del collo del femore. He continued as the editor of this out- standing medical journal until his death. He was an accomplished linguist and lectured by invitation in practically every country, includ- ing the United States, England, France, Germany, and Russia. He was a guest of the American Orthopedic Association at its Boston meeting in 1921, and delivered later the Lane lec- tures in California. He was the guest speaker at the Congress of the American College of 284 Who’s Who in Orthopedics Doctor’s Hospital in New York City, and from 1942–1945, during World War II. This invaluable war experi- ence crystallized his interest in the surgery of injuries. Although trained as a general surgeon and accredited as such by the American Board of Surgery, interest, opportunity, and circumstances gradually led him into the field of musculoskele- tal trauma. Quigley was associated with the Department of Thomas Bartlett QUIGLEY Hygiene and Athletics at Harvard University, 1908– eventually becoming head of the department. He once stated that “the care of these young men Thomas Bartlett Quigley was born on May 24, occupied one-third of my time; and constituted 1908 in North Platte, Nebraska, the son of Dr.

The Department of Health recommends that clients are told how in­ formation might be shared before they are asked to provide it spasms synonym purchase azathioprine 50 mg. This might be through the use of general information contained in leaflets and specific discussions between the client and the clinician as part of joint care plan­ ning spasms head purchase azathioprine 50mg amex. However muscle relaxant lorzone cheap azathioprine 50 mg online, it is recognised that in health care it would be impracticable and unnecessary to obtain the client’s specific consent each time informa­ tion needed to be passed on. Health professionals must be able to respond to the needs of clients promptly. Personal health information needs to be readily available so that the most appropriate and effective care is deliv­ ered. Therefore health organisations need to advise clients that their per­ sonal information may need to be shared amongst health staff and with associated agencies, in order to plan and co-ordinate care. The client has a right to refuse permission for information to be passed on (subject to the exceptions detailed below). Clinicians will need to re­ spect the wishes of the client in such cases. However it is important that cli­ ents are made aware of the likely implications of this decision for their own health care and the impact on effective management of health services in general. Children and young people There is often some confusion regarding the rights of children and young people with regard to consent and confidentiality when receiving health care. THE LEGAL FRAMEWORK 37 ° Young people aged 16 or 17 years of age have the right to consent to treatment unless there is evidence of a lack of capacity (the Family Law Reform Act 1969). Consequently such young people also have the same rights to confidentiality as adults. In other cases the person with parental responsibility, who has consented to treatment on behalf of the child, would be involved in decisions about passing on information. There are certain exceptions to the duty of confidentiality where informa­ tion may be disclosed. Below are some examples: ° Where there is a statutory requirement to pass on information, for instance notification of communicable disease, the Public Health (Control of Disease) Act 1984, the Mental Health Act (1983), the Prevention of Terrorism Act (1989). It may therefore be necessary to share information with specific professionals and agencies. This often relates to the prevention of serious crime but can include such matters as a public health risk. Any unwanted paperwork containing personal details about clients must be disposed of using processes that protect confidentiality. For instance, they should not reveal passwords or allow others access to the computer under their identity and password. Care should be taken that computer screens are not left unattended or in view of public areas. THE LEGAL FRAMEWORK 39 ° Clinicians need to ascertain, when sharing information about clients with other professionals, that they have the same requirements regarding confidentiality (Shaw 2001). Access to health records Clients have had the right to have access to automatically processed health records since the first Data Protection Act in 1984. This has now been re­ placed by the Data Protection Act (1998), which came into force on 1 March 2000. This Act permits access to all manual and electronic health records regardless of when they were created. It should be noted that this Act also repeals the Access to Health Records Act (1990), except for provi­ sions concerning the deceased. There are certain circumstances when access may be limited, for example: 1. Information may not be disclosed if it is thought that it might cause serious physical or mental harm to any person (including any health professional). Information about a third party may not be disclosed without their consent (although this does not include health professionals who may have been involved in compiling or contributing to the record). Where there is a statutory restriction on the disclosure of information; for example, the NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000, the Human Fertilisation and Embryology (Disclosure of Information) Act of 1992 both place limitations on the disclosure of certain information. These include persons authorised by the client, a representative appointed by a court of law to manage the client’s affairs, a legal representative of a deceased person or anyone having a claim arising from that client’s death. Clients not only have the right to access but also, where appropriate, the right to rectification. They may apply either through the courts or the Data Protection Commissioner to have any inaccurate data and opinions based on that data rectified or removed (Data Protection Act 1998).

The age of the patients at the time of surgery ranged from 15 to 49 years with a mean of 29 years; 13 patients were women and 27 were men spasms with ms cheap azathioprine online mastercard. Of the hips muscle relaxant for tmj purchase azathioprine 50mg amex, 23 had a history of corticosteroid administration muscle relaxant spray cheap azathioprine 50 mg line, 9 had a history of alcohol abuse, 10 had a history of femoral neck fracture, and 3 had a history traumatic dislocation; the remaining 3 hips had no apparent risk factor. We excluded 12 of 60 hips from the study because 7 hips were lost to follow-up, 4 hips were conver- sion surgery of a prosthetic replacement less than 3 years after posterior rotational osteotomy because of early recollapse after trauma, and 1 patient died of underlying disease. All 48 hips had extensive lesions from medial to lateral and from anterior to the posterior portion of the femoral head. No viable area was seen on the articular surface of the loaded portion of the femoral head facing the acetabular roof on preoperative anteroposterior radiographs (type C2 of criteria of Japanese Investigations Commit- tee) in all 48 hips. On correct lateral radiographs, the posterior viable area of joint surface of these hips before surgery ranged from 6% to 29% with a mean of 19%. All 48 hips had apparent Posterior Rotational Osteotomy in Femoral Head Osteonecrosis 91 collapse (greater than 3mm). In these hips, 40 hips showed no apparent joint space narrowing (stage 3B of criteria of Japanese Investigations Committee). Twenty-five cases were involved by osteonecrosis bilaterally on radiographs or magnetic resonance imaging. Of these hips, 11 were treated by bilateral posterior rotational osteotomy. Different procedures were elected for the contralateral hips of the other 14 cases: 2 anterior rotational osteotomies and 1 total hip arthroplasty. The remaining 4 cases were not treated because of small-size lesion without symptoms. Additional intentional varus positioning was done from 10° to 30° (mean, 19°) in all 48 hips to obtain an extensive noncollapsed viable articular surface of the femoral head in the loaded portion postoperatively. The rotational angle and intentional varus angle necessary for this procedure were determined by preoperative assessment, mainly on radiographic findings. Radio- graphs taken under these conditions can show the location and extent of the noncol- lapsed viable articular surface of the femoral head after posterior rotation. Magnetic resonance imaging and computed tomography can be available if the demarcation area between living and necrotic bone is not clearly visualized on radiographs. The modified Ollier approach as reported by Sugioka was employed in 1 remaining operation. For the fixation of osteotomy plane after femoral head rotation, we used large screws (Sugioka) in 4 hips, an AO screw in 2, and an AO plate in 2. However, these fixation devices were not strong enough to allow for early motion. Thereafter, the authors made and used a customized device developed by Atsumi [7,8] in 40 hips. Patient population Forty-eight hips, of 40 young patients Age, 15–49 years old (mean, 29 years) Sex: 13 women, 27 men Etiological factor: Steroid administration, 23 hips Alcohol abuse, 9; traumatic, 13 No apparent factor, 3 Type C2: 48 hips (no viable area on articular surface of the femoral head of loaded portion on preoperative anteroposterior radiographs) Stage 3B, 40 hips; 4, 8 hips (all 48 showed >3mm collapse) Anterior or posterior viable area on correct lateral radiographs Anterior, 6%–42% (mean, 21); posterior, 6%–29% (mean, 19) Posterior rotational angle: 70°–160° (mean: 126°) Additional varus position 10°–25° (mean, 19°) Follow-up, 3–20 years (mean, 9. A C B D E F Posterior Rotational Osteotomy in Femoral Head Osteonecrosis 93 Table 2. Extent of viable area of femoral head on postoperative AP and 45° flexion AP radiographs Group A Group B Group C 2/3 1/3, 2/3 <1/3 Conventional AP (n = 48) 15 (31%) 27 (56%) 6 (13%) 45° Flexion AP (n = 48) 10 (21%) 33 (69%) 5 (10%) AP, anteroposterior For postoperative management, partial weight-bearing was permitted 5 to 6 weeks after operation using two crutches. Gait with one crutch was essential for 6 months to 1 year depending on the extent of lesion. Radiographic outcome was influenced by the extent of the lateral noncollapsed living area of the femoral head corresponding to the acetabular roof on postoperative conventional anteroposterior radiographs. Extent of the noncollapsed viable area of the loaded portion of the femoral head was measured by angle, and the rate of extent was divided into three groups as follows: group A, less than the medial one- third of the weight-bearing area is involved; group B, more than one-third but less than two-thirds is involved; and group C, more than two-thirds is involved (Table 2). Anteroposterior radiographs were also taken in 45° of hip flexion [(7,8)] to observe the anterior viable portion of the femoral head. The extent of the viable area of the anterior femoral head was also divided into three groups as well on conventional anteroposterior radiographs. Prevention and progression of recollapse and progres- sive joint space narrowing were observed on the follow-up radiographs, and the relationship with the extent of viable articular surface of the femoral head was also studied. Of the remodeling after surgery, respherical contour on the collapsed area that moved medially and improvement of degenerative joint narrowing were investi- gated. The necrotic focus was moved to the medial portion of the femoral head on postoperative anteroposterior radiographs in all 48 hips. A 30-year-old woman receiving high doses of corticosteroids for treatment of multiple sclerosis.

No doubt muscle relaxant 2 generic azathioprine 50 mg online, their political outlook influenced their style of practice gastrointestinal spasms order azathioprine toronto, but most patients would have scarcely been aware of where to place their doctor on the political spectrum muscle relaxant triazolam cheap azathioprine 50 mg free shipping. 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. Thus, for example, the split between fundholding and non-fundholding GPs in the early 1990s loosely reflected party-political allegiances as well as the divide between, on the one hand, suburban and rural practices, and on the other, those in inner cities. Despondent at the wider demise of the left, radical doctors turned towards their workplaces and played an influential role in implementing the agenda of health promotion and disease prevention, and in popularising this approach among younger practitioners. Allowing themselves the occasional flicker of concern at the victimising character of official attempts at lifestyle modification, former radicals reassured themselves with the wishful thinking that it was still possible to turn the sow’s ear of coercive health promotion into the silk purse of community empowerment. Reflecting the wider exhaustion of the old order throughout Western society, an older generation of more conservative and traditional practitioners either capitulated to the new style or grumpily took early retirement. In 1987 I co-authored The Truth About The Aids Panic, challenging the way in which the ‘tombstones and icebergs’ campaign had grossly exaggerated the dangers of HIV infection in Britain, causing public alarm out of all proportion to the real risk (Fitzpatrick, Milligan 1987). Though the central argument of this book was rapidly vindicated by the limited character of the epidemic, it received an overwhelmingly hostile response, particularly from the left. Radical bookshops either refused to stock it or insisted on selling it with an inclusion warning potential readers that it might prove dangerous to their health. In public debates I was accused of encouraging genocide and there were demands that I should be struck off the medical register. My argument that safe sex was simply a new moral code for regulating sexual behaviour provoked particular animosity from those who took the campaign’s disavowal of moralism at face value. Not only does moralism not need a dog collar, in the 1990s it was all the more effective for being presented through the medium of the Terrence Higgins Trust, once aptly characterised as the Salvation Army without the brass band. Given the pressures of full-time general practice, intensified by the various government reforms and campaigns, this project took rather longer than intended and, in 1996. This was rejected by the Department of Health on the grounds that the proposed project was not ‘in the interests of medicine in a broad sense or otherwise in the interests of the NHS as a whole’. The fact that I was obliged to carry on working on this project in the interstices of the working day has meant that it has taken rather longer than anticipated. This has, however, enabled me to take into account the accelerated development of some of the trends of the early 1990s in the period since New Labour’s electoral triumph in 1997. The scope of government intervention in personal life through the medium of health has expanded—into areas such as domestic violence and parenting—and it has become more authoritarian— notably in the programme for maintaining heroin users on long-term methadone treatment. Yet the remarkable feature of New Labour’s public health initiatives is that they have provoked virtually no criticism either from the world of medicine or from that of politics, from any part of the political spectrum. The collapse of both the old left and the new right gives New Labour unprecedented authority to push forward both its authoritarian public health policy and its ill-considered programme of ‘modernisation’ in the health service. Whatever the fate of Tony Blair’s subordination of the NHS to electoral expediency, it is time to expose the deeper processes of the medicalisation of life and the corruption of medicine. In relation to my earlier dispute with the Department of Health, I would like to acknowledge the support of Diane Abbott, Mildred Blaxter, Gene Feder, Michael Neve, Peter Toon and Tony Stanton. In relation to this book, I am especially grateful to Mary Langan for assistance in many areas and to my medical colleagues Matthew Bench, Tricia Bohn, Gabriella Clouter, Chris Derrett, Janet Williams and Fayez Botros. Thanks are also due to Toby Andrew, Jennifer Cunningham, John Fitzpatrick, Liz Frayn, Heather Gibson, John Gillott, Sally Goble, James Heartfield, Brid Hehir, Gavin Poynter, Mark Wilks. I am particularly thankful to Mick Hume, the x PREFACE courageous editor of LM magazine, where many of the ideas developed here first appeared. I also pay tribute to all the staff and patients at Barton House Health Centre to whom this book is dedicated. Michael Fitzpatrick April 2000 xi GLOSSARY OF ACRONYMS ADHD Attention Deficit Hyperactivity Disorder Aids Acquired Immune Deficiency Syndrome ASH Action on Smoking and Health BMA British Medical Association BMJ British Medical Journal BSE Bovine Spongiform Encephalopathy (aka Mad Cow Disease) CHD Coronary Heart Disease CJD Creutzfeldt-Jakob Disease (also nvCJD: new variant CJD) CMO Chief Medical Officer DHSS Department of Health and Social Security DoH Department of Health ETS Environmental Tobacco Smoke (inhaled by passive smokers) GMC General Medical Council GP General Practitioner HIV Human Immunodeficiency Virus ME Myalgic Encephalomyelitis (aka Chronic Fatigue Syndrome) NHS National Health Service NICE National Institute of Clinical Excellence PHA Public Health Alliance RCGP Royal College of General Practitioners RCP Royal College of Physicians RCPsych Royal College of Psychiatrists UNICEF United Nations Children’s Fund WHO World Health Organisation xii 1 INTRODUCTION We live in strange times. People in Western society live longer and healthier lives than ever before. There is a widespread conviction that the modern Western diet and lifestyle are uniquely unhealthy and are the main causes of the contemporary epidemics of cancer, heart disease and strokes.

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