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By O. Flint. Cleveland Chiropractic College.

T he environm ental insults of the industrial age—contam inated water and lack o f sanita­ tion order 100 mg voveran sr, the unavailability of basic nutrients discount 100 mg voveran sr visa, uncontrolled epidemics and an inadequate understanding of infectious transmission— have been mostly m anaged. These include air quality, chemical treat­ ments o f foodstuffs and other products, overindulgence in food and drugs, stress, the pace of life, congestion, noise, and the lack of recreation and exercise. T he contribution of medical care was m inor in the adaptation o f man to the industrial threats to health; and similarly, it has only a m inor role to play in the adaptations that now face us. T he reason lies in the paradigm o f health that medicine has con­ A New Paradigm 213 ceived—the “science of the organized individual,” to use A. Crombie elaborates: The biology of the individual is more like engineering than physics, in that each type of living organism is a solution to a specific set of engineering problems—problems of intake and conversion of fuel, locomotion, communication, replication and so on which it has to solve to survive. This subject matter has imposed on physiology its characteristic program: to find out how an organism works by taking it to pieces and trying to put it together again from knowledge of the parts. As a result it has sought to engineer hum an health through the m anipulation o f hum an parts. John Powles has examined this question in some detail in his paper “O n the Limitations of M odern Medicine”: The engineering approach to the improvement of health has been dominant over an alternative approach which would em­ phasize the importance of way of life factors in disease—an approach which could be described as “ecological. Curative medicine has not been very successful in reducing the impact of diseases of maladaptation. Despite the evidence to the contrary, it is widely believed by both patients and their doctors that industrial populations owe their high health standards to “scientific medicine,” that such medi­ cal technology as currently exists is largely effective in coping with the tasks it faces and that it offers great promise for the future. There was only one question Ivan Illyich wanted answered: was his condition dangerous or not? One had only to weigh possibilities: floating kidneys, chronic catarrh, or an ailment of the caecum. There was no question of the life of Ivan Illyich—nothing but a contest between floating kidneys and the caecum. In the presence of Ivan Illyich the doctor gave a brilliant solution to the problem in favour of the caecum, with the reservation that the analysis of his water might supply new information necessitating a reconsideration of the case. But it is in the relationship be­ tween hum an beings and their environm ent that the key to health lies. H ealth then is not ju st the well-oiled functioning o f the body—it is achieved through the strategic collabora­ tion o f hum an beings with their world expressed through a series o f “relationships. T h e physician can help, but the individual m ust be responsible for those relationships. It is individuals who m ust “learn” to control bodily processes, including those heretofore considered involuntary. A nd it is individuals who m ust discover their higher, m ore spiritual, capacities by expanding their consciousness and self-awareness. W hen even modest reform is difficult, revolution may appear to be rom antic escapism. If the moral and conceptual underpin­ ning under medicine erodes, as I have suggested it will, the revolution in medicine will be bloodless because it will take place at the level o f concepts. But since shifts in values and attitudes often occur slowly, som ething dramatic is needed now. Moreover, inescapable pres­ sures are m ounting for reform o f the system within conven­ tional bounds. Consequently, unless revolutionary concepts can be form ulated out of which new approaches grow, the changes that will occur will strengthen the existing delivery system. W hat is needed is a shift in paradigm s, not organiza­ tional and financing reform s. Health is not a commodity for packaging, seller to buyer, but a rich web o f causes, effects, and interactions. Resources play a part, as does social and environm ental engineering; but individuals must also inte­ grate their own knowledge with the use o f healers. Underlying these reform s is the need for a radical recon­ ceptualization o f health and behavior related to health. T he most fundam ental message o f this book is that no am ount of social and systems engineering will replace the need to think differently about health. Chief am ong them is the institutional pressures of medicine in the United States. It is the largest social service system in the world, and it employs m ore people than any other sector of the economy, with the exception of education. Any proposal to reduce the size of the system will necessarily m eet strong resistance. O ther problems include the lack o f a coherent policy for the aged, the value preferences of an indulged 216 The Transformations of Medicine public that chooses chewing gum, sugar, fatty foods, high­ speed cars, and spectator sports; and the power of industries that m arket the products that a complacent, ignorant public consumes. Since resistance will be fierce, some of the specific objections can be anticipated.

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Funding provided for researching the cause cheap voveran sr 100mg without a prescription, Baxley Professor of Pathology [1901]: J buy voveran sr 100mg amex. Henry Willis Andelot Professor of Laryngology and Baxley (1824-1876) provided funding for the Otology [1962]: Unoccupied. The Andelot name was selected war practiced his profession in Baltimore and by Mr. Stanhope Bayne-Jones Professorship in Dana and Albert “Cubby” Broccoli Profes- Medicine [1974]: David L. As an expert in infectious used to endow a Professorship in Oncology, diseases, he served on the faculty of the Uni- having an initial focus on research and treat- versity of Rochester and Yale Medical Schools, ment of breast cancer. Brody Professorship in Radiol- he was made a brigadier general in the Army ogy [1992]: Martin G. Brody who was the Director Bendann-Iliff Professorship in Ophthal- of the Department of Radiology from 1987- mology [1995]: Nicholas T. Brody was appointed Pres- Funding provided by Constance, Maurice, ident of the Johns Hopkins University. Bernheim Research Pro- in the Division of Hand Surgery [2000]: fessorship in Surgery [1968]: James Black, Thomas M. Thornhill to provide faculty support in the by members of the Bernheim family to honor Division of Hand Surgery, Department of Bertram M. Professorship for of the faculty of the Department of Surgery, Alimentary Tract Diseases in the Depart- he was responsible for pioneering research ment of Surgery [2002] Richard D. Neurosurgery [2007]: Benjamin Carson, Funding for this Chair was by contributions M. Alfred Blalock Funding for this professorship was provided was Director of the Department of Surgery by Mr. Tom Clancy Professorship in Ophthalmol- Funding for this Chair was provided by the ogy [2005]: Unoccupied. McCarthy-Cooper Estate, patients, and resi- Funding for this professorship was provided dents of Dr. Bordley, who was Direc- by Tom Clancy, a friend of Johns Hopkins tor of the Department of Otolaryngology for Medicine and Johns Hopkins Board of Visi- 17 years (1952-1969). Clayton Professorship in Oncology [1984]: Boury Professorship in Molecular Biology Bert Vogelstein, M. Clayton of This Professorship was funded by a bequest Houston, Texas created the Clayton Fund in the will of Mr. Boury which was used to support projects in car- was a native of Baltimore who moved to New diovascular disease under the direction of Dr. Breast Cancer Research Professorship in Professorship in the Clinical Care and Oncology [1992]: Occupied by Vered Stea- Research of Pediatric Endocrinology rns, M. Plotnick’s retirement, the name Richard Bennett Darnall Chair in Surgery of the endowed professorship will become [1964]: Unoccupied. Professorship in Funding provided by a bequest in the will the Clinical Care and Research of Pediatric of Mrs. Richard Bennett Darnall Professor Emeri- Funding provided from the bequest of Mrs. Funding provided by the estate of Admiral Funding provided by a bequest in the will of Conner. DeLamar, who was born in the chair shall be the Director of the Harriet Holland in 1843 and came to America after the Lane Clinic. On the advice of Funding provided from income from the prin- his attorney, he divided his $30 million estate cipal which will be used “in honor of Dr. David between the “three best medical schools of the Hellmann and that the holder of the chair be day -Johns Hopkins, Harvard and Columbia”. Cudahy, the Funding provided by contributions of current founder of Marquette Electonics, which pro- and former faculty, fellows, and house staff duces medical, diagnostic, monitoring and of the Department of Radiology. Otolaryngology - Head and Neck Surgery Clarence Doodeman Professorship in [2005]: Unoccupied. Funding provided by Edward and Loretta Harvey Cushing Professorship in Neuro- Downey to honor Mrs. Funding provided by the Eccles Foundation Firor as a fne surgeon, teacher, and humani- and by Mrs. Edgerton Endowment in Pediatric Epilepsy [2009]: for an endowed professorship for the Director Unoccupied of the Department of Plastic and Reconstruc- Funding will be used for pediatric epilepsy. Jonas Friedenwald Professorship in Oph- Doctor Dorothy Edwards Professorship in thalmology [2004]: Unoccupied. Gynecology and Obstetrics [1986]: Harold Named for father of experimental ophthalmic E. Fries Professorship in Medicine Edwards, who attended the Johns Hopkins [2006]: Unoccupied School of Medicine from 1917-1921. Funding provided by the Garrett Fund for the Eudowood Professorship in Pediatric Immu- surgical treatment of children founded by nology [1986]: Jerry A. Eudowood was the name of a tubercu- losis hospital offcially known as The Hospital William Thomas Gerrard, Mario Anthony for Consumptives of Maryland, which joined Duhon and Jennifer and John Chalsty with other institutions to form the Children’s Professorship in Urology [1998]: William B.

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Pretreatment with insulin was found to limit the Among the factors found to contribute to the ischemia buy cheap voveran sr 100mg on line. Glucose level is an important risk factor for morbid- In one systematic study [24b] it was shown that ity and mortality after stroke purchase voveran sr 100 mg visa, but it is unclear glucose pathology is seen in up to 80% of acute whether hyperglycemia itself affects stroke out- patients, many of them showing a high probability comes or reflects the severity of the event as a of previously unrecognized diabetes. The study was conducted among 933 hyper- pre-thrombolysis patients, an even more aggres- glycemic acute stroke patients who received glucose- sive approach may be advisable. In the treatment group significantly lowered glucose and blood pressure values were documented; however, Hyperthermia no clinical benefit was found among the treated Several animal studies [35, 36] demonstrated the cor- patients. The time window for treating post-stroke relation of elevated temperature and poor outcome in hyperglycemia still remains uncertain. Similar results were found in variety of methods of insulin administration, includ- human observations. Patients with hyperglycemia temperature was recorded every 2 hours for 72 hours (glucose > 6. Hypothermia was A randomized, multicenter, blinded pilot trial, introduced more than 50 years ago as a protective Treatment of Hyperglycemia in Ischemic Stroke measure for the brain [39]. The aggressive-treatment group was associ- hours after brain injury was not found to be effective ated with somewhat better clinical outcomes, which [41]. Other applications for which therapeutic hypo- were not statistically significant. According to the American high doses ranging between 3900 and 6000 mg daily guidelines [21], even lower serum glucose levels, pos- [42,43], caused only very mild reduction in body sibly between 140 and 185 mg/dl, should trigger temperature, ranging from 0. Despite the current recom- The clinical benefit of this reduction is not well estab- mendation, a more aggressive approach is advised, lished. The use of external cooling aids [44], such as especially in pre-thrombolysis patients. Many ques- cooling blankets, cold infusions and cold washing, tions surrounding the role of glucose lowering ther- aiming at a body temperature of 33 C for 48 to 72 apy remain unanswered [32]. What level of blood hours in patients with severe middle cerebral artery glucose is best for intervention? How long should the insulin Similar results, of decreasing acute post-ischemic Chapter 17: Management of acute ischemic stroke and its complications cerebral edema, were found in a small pilot study Summary of endovascular induced hypothermia [45]. The use Optimal management of hypertension following of an endovascular cooling device which was inserted stroke has not been yet established. A U-shaped rela- into the inferior vena cave was evaluated among tionship between baseline systolic blood pressure and patients with moderate to severe anterior circulation both early death and late death or dependency has territory ischemic stroke in a randomized trial. Stroke patients with impaired consciousness results suggest that this approach is feasible and that showed higher mortality rates with increasing blood moderate hypothermia can be induced in patients pressure. However, the current data do not support the pressure reduction as a secondary prevention of use of induced hypothermia for treatment of patients stroke is well established, but only a few trials have with acute stroke. However, these few peutic potential, hypothermia as a treatment for trials demonstrate a beneficial effect of lowering acute stroke has been investigated in only a few very blood pressure. According to the is still thought of as experimental, and evidence of American guidelines, indication to treat blood pres- efficacy from clinical trials is needed [47]. Glucose level is febrile or non-febrile patients with antipyretics is an important risk factor for morbidity and mortality not proven. In pre-thrombolysis In summary, hypertension, hyperglycemia and patients, an even more aggressive approach may be hyperthermia are common conditions following acute advisable. All three have a major and independent Hyperthermia within the first 24 hours from impact on the severity of outcome. Occasionally, the stroke onset was associated with larger infarct volume benefit of this impact is no less than that of more and worse outcome. Mild induced hypothermia “heroic” strategies such as intravenous and intra- was found to improve neurological outcome and arterial thrombolysis. Despite the lack of consensus reduce mortality following cardiac arrest due to on the data and optimal management, one should ventricular fibrillation, but the current data (few very carefully monitor these three “hyper links” and treat small studies) do not support the use of induced them appropriately. General stroke treatment recommendations Association recommendations in the acute stroke phase. A post-stroke seizure is defined as early if it Administration of anticonvulsants is recommended occurs in the first 2 weeks after the stroke. A seizure to prevent recurrent post-stroke seizures (Class I, occurring later is defined as late [49]. Prophylactic administration of The estimated rate of early post-ischemic stroke anticonvulsants to patients with recent stroke seizures ranges from 2 to 33% and that of late seizures who have not had seizures is not recommended varies from 3 to 67% [50–58]. In an observational study among 1428 patients Bisphosphonates (alendronate, etidronate and after stroke [58], 51 patients (3. In a prospective study comparing lamotrigine versus carbamazepine in 64 patients with post-stroke Post-stroke epilepsy is defined as at least two epi- epilepsy, lamotrigine was found to be significantly sodes of seizures. The overall rate is 3–4% of stroke tolerated and with a trend to be also more efficacious patients. Other predictors for post-stroke seizures found in various studies are cortical location, large infarct, There is no evidence to prefer one antiepileptic drug over the others, but it is advised to avoid evaluated clinically or radiologically, intracerebral phenytoin because of interactions with anticoagu- hemorrhage and cardiac emboli, most probably due lants and salicylates.

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Institute of Medicine purchase voveran sr 100 mg with mastercard, Committee on Crossing the Quality Chasm:Adaptation to Mental Health and Addictive Disorder generic voveran sr 100mg. Institute of Medicine, Committee on Crossing the Quality Chasm:Adaptation to Mental Health and Addictive Disorder. Institute of Medicine, Committee on Crossing the Quality Chasm:Adaptation to Mental Health and Addictive Disorder. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Obstacles to carrying out brief intervention for heavy drinkers in primary health care: A focus group study. Early adoption of injectable naltrexone for alcohol-use disorders: Findings in the private-treatment sector. A longitudinal examination of alcohol pharmacotherapy adoption in substance use disorder treatment programs: Patterns of sustainability and discontinuation. Relationships between personality and preferred substance and motivations for use among adolescent substance abusers. Baclofen efficacy in reducing alcohol craving and intake: A preliminary double-blind randomized controlled study. Dose- response effect of baclofen in reducing daily alcohol intake in alcohol dependence: Secondary analysis of a randomized, double-blind, placebo-controlled trial. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: Randomized, double-blind controlled study. Mental and substance use disorders among Medicaid recipients: Prevalence estimates from two national surveys. Table 3: Total expenses and percent distribution for selected conditions by type of service: United States, 2009. Interagency guideline on opioid dosing for chronic non-cancer pain: An educational aid to improve care and safety with opioid therapy: 2010 update. Are there genetic influences on addiction: Evidence from family, adoption and twin studies. Clinical psychologists and smoking cessation: Treatment practices and perceptions. Detoxification from alcohol: A comparison of home detoxification and hospital-based day patient care. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. Development of an instrument to identify barriers to treatment for addicted women from their perspective. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. Efficacy of daily and alternate-day dosing regimens with the combination buprenorphine-naloxone tablet. Effectiveness of interventions on opiate withdrawal treatment: An overview of systematic reviews. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: Available evidence to inform clinical practice and research. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Rationale for screening and brief intervention for alcohol problems in primary care. American Academy of Pediatrics, Committee on Substance Abuse and Committee on Children With Disabilities. Standards for accreditation of baccalaureate and graduate degree nursing programs. The need for addiction medicine physicians and for addiction medicine residency training programs: A report of The American Board of Addiction Medicine Foundation. Content outline: Pediatric emergency medicine subspecialty in- training, certification, and maintenance of certification examinations. Content outline: Adolescent medicine subspecialty in-training, certification, and maintenance of certification examinations. Content outline: Child abuse pediatrics subspecialty in-training, certification, and maintenance of certification examinations. Content outline: Neonatal-perinatal medicine subspecialty in- training, certification, and maintenance of certification examinations. Content outline: Developmental-behavioral pediatrics subspecialty in-training, certification, and maintenance of certification examinations. Subspecialty certification examination in forensic psychiatry: 2009 content outline. Subspecialty certification examination in psychosomatic medicine: 2009 content outline. Subspecialty certification examination in geriatric psychiatry: 2010 content outline. Written certification examination in child and adolescent psychiatry (Part 1): 2010 content outline.

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