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By Q. Milok. University of Hartford. 2018.

Albert wit and complete integrity 100 mg zenegra free shipping, which made him Key was one of the 32 students who volunteered purchase 100mg zenegra free shipping, respected and loved by innumerable friends in and, when the United States entered the war, he every walk of life. Professor Lipmann Kessel died enlisted with the others as a private in the Army in London on June 5, 1986, aged 72, leaving be- Medical Corps. The months that followed were hind his wife, two sons and two daughters. There it occupied a hospital with barracks built around a central building, which was called “the chateau. During the spring of 1918 the students received cablegrams from their university, informing them that they had been awarded their degrees as Doctors of Medicine. Soon after Albert was transferred, and in the months that followed, he worked with a rehabili- tation battalion, which had been organized under the general planning of Dr. Key courted and married Eleanor Myer, an attractive nurse affiliated with the unit. Key 1890–1955 was greatly admired for his rare devotion to his family, and when John Albert, Jr. Key attended the Alabama Polytechnic Insti- missing in action while serving as an air force tute where he earned a Bachelor of Science pilot in the Pacific Theater in 1943, intimate degree in 1913, following which he entered Johns friends were convinced that Dr. Key would never Hopkins University as a member of the class of recover from the shock of the tragedy. In training at the Children’s Hospital and Massa- discussion, although he always spoke with frank- chusetts General Hospital in Boston. A portion of ness, vigor, and honesty, his never-failing genial- this time was spent with Dr. Key received without a barb; his brilliant logic and even his general surgical training. During the latter temper, his willingness to allow others to explore part of this time, he was resident in orthopedic the great reaches of his intellect and tremendous surgery at Massachusetts General Hospital on the mental capacity, gave him his rightful place as service of Dr. Goldthwait counsellor, guide, and mentor in matters orthope- was then at Devereaux House in Marblehead, dic. He made the words “orthopedic surgery” and Massachusetts, and with ambitious energy, Albert “progress” almost synonymous, and he ranks also followed courses there, meanwhile having among those who laid the foundation for ortho- garnered a Peabody scholarship. Key had begun of his time on that scholarship to undertake some fundamental research early in his career and never hematological investigations. He continued his work attracted to hematology during his first year in along these lines and always correlated his medical school and was particularly interested in research work with the clinical approach. In spite of his multitudinous duties at the His endeavors in this field were successful, and Shriners’ Hospital, his enormous ability for work he published two important papers: “Studies on enabled him to make outstanding contributions Erythrocytes with Especial Reference to Reticu- in experimental and clinical studies. During this lum, Polychromatophilia and Mitochondria” and period, “The Reformation of Synovial Membrane “Lead Studies. Blood Changes in Lead Poi- in the Knees of Rabbits After Synovectomy,” soning in Rabbits with Especial Reference to the “The Mechanisms Involved in the Removal of Stippled Cells. Fluid of Normal Joints” were among his out- In 1921 he became instructor in applied phys- standing works. The Reactions of Joints to In 1924, it was the aim of the National Advi- Mild Irritants” and “The Pathogenic Properties of sory Board of the Shriners’ Hospitals for Crippled Organisms Obtained from Joints in Chronic Children to have their institutions throughout the Arthritis. His results were the investigation of the cause, prevention, and published under the titles “Experimental Arthri- treatment of crippling conditions in childhood. Key was appointed director of research for all Defects in the Articular Cartilage” and “Trau- the Shriners’ Hospitals, with headquarters in St. Childhood,” “The Non-Tuberculous Hip in have had the opportunity to observe Dr. Adolescence,” and “Some Diag- research, to become familiar with his ability as nostic Problems in the Hip in Early Life. Key wrote an article on brittle bones students, and to be stimulated by his keen inter- and blue sclera, which he termed “hereditary est in the clinical problems of crippled children. More than bones, and joints, in a case studied from the clin- simply a colleague, Albert became my friend, and ical, roentgenographic, and laboratory aspects. Furthermore, he became his thesis for membership in the American Ortho- interested in the School of the Ozarks. He contributed two sections, a small Missouri school whose interests were one on “Idiopathic Bone Fragility (Osteopsathy- directed mainly toward the education of under- rosis)” and the other “Fractures and Dislocations privileged children.

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Living with cerebral palsy and tube feeding: a popula- tion-based follow-up study discount zenegra 100 mg with amex. Migraine is a common childhood disorder characterized by recurrent headaches cheap zenegra 100mg with amex. Most children with migraine are symptom free between episodic headache attacks. Headache frequency and severity increase over time for a subset of pediatric migra- neurs. Chronic migraine headache, transformed migraine, chronic nonprogressive headache, and chronic daily headache probably represent a spectrum of migraine headache syndromes. As headaches increase in severity and=or frequency, patients and their families are likely to experience significant disability. The burden of chronic migraine not only includes severe head pain but also missed school and extracurri- cular activities, academic underachievement, depressed mood, and anxiety. This chapter will focus on therapeutic approaches to chronic headache syndromes; acute therapies are covered. The goal of preventative treatment should be to decrease significantly the frequency and severity of migraine headache, improve quality of life, and increase the effectiveness of abortive therapy. There is no fixed number of headaches per month that requires prophylaxis. Pharmacologic therapy is usually started when headache begins to interfere with a patient’s activities, or when abortive therapy becomes less effective because of overuse (Table 1). Physicians should help patients develop realistic expectations about the limits of treatment for this chronic disorder. Responsibility for headache control should be shared among patient, family, and physician. Patients and physicians often find that a headache diary recording both frequency and severity of attacks as well as possible trigger factors is useful in monitoring the efficacy of treatment. Table 1 When to Consider Preventative Medication Recurrent headaches that interfere significantly with daily activities Ineffectiveness or contraindications to abortive medication Analgesic overuse Very frequent headaches Patient preference Headaches with significant neurologic threat (i. Caffeine, chocolate, mono- sodium glutamate, processed and smoked meat and fish, nuts, vinegar and red wine, citrus fruits, cheeses (especially aged), and aspartame tend to precipitate headache in susceptible individuals. Foods like hotdogs, some corn and potato chips, pizza, soda, and peanut butter must be included on any list for children. Skipping meals, espe- cially during the school day, can lead to headache. Dehydration, especially in the summer and during sports, is an under recognized trigger in many children. The hormonal changes of puberty may trigger an increase in head- aches several months to years before menarche or obvious external signs are present. The cyclical nature of many girls’ headaches suggests a hormonal component. Use of over-the-counter or prescription medication for acute migraine (NSAIDS, aceta- minophen, triptans) more than three times a week can lead to an increase in head- aches and poor response to abortive medication. A timely (or rather untimely) Figure 1 A strategy for headache prevention. Migraine Prevention 227 combination of trigger factors often culminates in a migraine attack in susceptible individuals. Identification of triggers and modification of lifestyle often result in a decrease in headaches. In general, a preventative medication is chosen for its efficacy as well as side effect profile (Table 2). Consideration should be given to comorbid conditions and concurrent medication use (Fig. A single medication should be started at low doses and titrated gradually upward to the effective or maximum dose.

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Neither serum nor tissue calcium concentrations fall after cardiac arrest; bolus injections of a calcium salts increase intracellular calcium concentrations and may produce myocardial necrosis or uncontrolled myocardial contraction purchase 100 mg zenegra. Smooth muscle in peripheral arteries may also contract in the Sodium bicarbonate in cardiac arrest presence of high calcium concentrations and further reduce ● Bicarbonate exacerbates intracellular acidosis because the blood flow buy zenegra 100 mg line. The most effective treatment for this reduced aortic pressure and a consequential reduction in coronary perfusion condition (until spontaneous circulation can be restored) is chest compression to maintain the circulation and ventilation to provide oxygen and remove carbon dioxide. Sodium bicarbonate Much of the evidence about the use of sodium bicarbonate has come from animal work, and both positive and negative results have been reported; the applicability of these results to humans is questionable. No adequate prospective studies have been Alternatives to sodium bicarbonate performed to investigate the effect of sodium bicarbonate on ● These include tris hydroxymethyl aminomethane (THAM), the outcome of cardiac arrest in humans, and retrospective Carbicarb (equimolar combination of sodium bicarbonate studies have focused on patients with prolonged arrests in and sodium carbonate), and tribonate (a combination of whom resuscitation was unlikely to be successful. Advantages THAM, sodium acetate, sodium bicarbonate, and sodium have been reported in relation to a reduction in defibrillation phosphate) thresholds, higher rates of return of spontaneous circulation, ● Each has the advantage of producing little or no carbon dioxide, but studies have not shown consistent benefits over a reduced incidence of recurrent VF, and an increased rate of sodium bicarbonate hospital discharge. Benefit seems most probable when the dose 79 ABC of Resuscitation of bicarbonate is titrated to replenish the bicarbonate ion and D-aspartate (NMDA) receptor, which has a role in controlling given concurrently with adrenaline (epinephrine), the effect of calcium influx into the cell, has been studied, but which is enhanced by correction of the pH. Its action as a buffer depends on the excretion Free radicals of the carbon dioxide generated from the lungs, but this is Oxygen-derived free radicals have been implicated in the limited during cardiopulmonary arrest. During both sodium bicarbonate can be recommended, and correction of ischaemia and reperfusion the natural free radical scavengers acidosis should be based on determinations of pH and base are depleted. Arterial blood is not suitable for these measurements; radical scavengers (desferrioxamine, superoxide dismutase, and central venous blood samples better reflect tissue acidosis. On the basis of the potentially detrimental effects described above, many Early attempts at cerebral protection aimed at clinicians rarely give bicarbonate. However, it is indicated for reproducing the depression in brain cardiac arrest associated with hyperkalaemia or with tricyclic metabolism seen in hypothermia, and antidepressant overdose. Two recent studies have shown improved neurological outcome with the Pharmacological approaches to induction of mild hypothermia (33 C) for 24 hours after cardiac arrest (see Chapter 7) cerebral protection after cardiac arrest The cerebral ischaemia that follows cardiac arrest results in the rapid exhaustion of cerebral oxygen, glucose, and high-energy phosphates. Cell membranes start to leak almost immediately Summary and cerebral oedema results. Calcium channels in the cell ● The use of drugs in resuscitation attempts has only rarely membranes open, calcium flows into the cells, and this triggers been based on sound scientific or clinical trial evidence a cascade of events that result in neuronal damage. Several mechanisms ● All drugs have a risk of adverse effects but the magnitude of for this have been proposed, including vasospasm, red cell these is often difficult to quantify sludging, hypermetabolic states, and acidosis. The Treatment of cerebral oedema obstacles to such research are formidable but must be tackled Immediately after the return of spontaneous circulation so that future resuscitation practice can be based on sound cerebral hyperaemia occurs. After 15-30 minutes of reperfusion scientific evidence global cerebral blood flow decreases, which is due, in part to ● Finally, remember that most patients who survive cardiac cerebral oedema, with resulting cerebral hypoperfusion. Corticosteroids increase the risk of infection and gastric haemorrhage, and raise blood glucose concentration but no evidence has been found to support their use. Calcium channel blockers Because of the role that calcium may play in causing neuronal Further reading injury, calcium channel blocking drugs have been investigated ● Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock resistant and in several clinical trials. Section 5 only the voltage-dependent L type is blocked by the drugs pharmacology 1: agents for arrhythmias. Resuscitation studied, so excess calcium entry may not have been prevented 2000;46:135-53. Section 6 Pharmacology 2: Agents to optimize under the trial conditions. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation Recently, the excitatory amino acid neurotransmitters (ARREST). The N-methyl- 80 17 Cardiac pacing and implantable cardioverter defibrillators Michael Colquhoun, A John Camm Cardiac pacing An artificial cardiac pacemaker is an electronic device that is designed to deliver a small electrical charge to the myocardium and thereby produce depolarisation and contraction of cardiac muscle. The charge is usually applied directly to the endocardium through transvenous electrodes; sometimes epicardial or oesophageal electrodes are used. They are all specialised invasive techniques and require considerable expertise and specialised equipment. Non-invasive external pacing utilises cutaneous electrodes attached to the skin surface and provides a quick method of achieving pacing in an emergency situation. It is relatively easy to perform and can, therefore, be instigated by a wide range of personnel and used in environments in which invasive methods cannot be employed. Increasingly, the defibrillators used in the ambulance service and the coronary care unit incorporate the facility to use this type of pacing.

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When the publishers offered to print a limited number of pictures for the second edition zenegra 100 mg on-line, Alan Apley’s typical response discount zenegra 100 mg visa, involving much labor was to produce that number of composites, each containing a large number of postage-stamp, but perfectly adequate, images. Keeping this book up to date would have daunted many, but not until Alan Graham APLEY the sixth edition did he recruit Louis Solomon as 1914–1996 coauthor. It is now in its seventh edition as Apley’s System and a concise version is in its second Alan Apley was born in London, the youngest edition. It is so popular throughout the world that son of Polish parents; his father had served in the pirated editions have appeared, which Alan found Russian Army. His latest work with Professor brothers and one sister all showed the intelligence Solomon on clinical examination will now be and energy often seen in second-generation published posthumously, although he saw an immigrants. Many other books had Council schools in Battersea and at the Regent the very considerable benefit of his coauthorship, Street Polytechnic led him to medical studies at editing or other assistance. He qual- The FRCS courses continued, becoming ified MB BS in 1938 and became a Fellow of the known as the “Apley” course. He 13 Who’s Who in Orthopedics always responded, using to advantage his won- improved, and rememorized for the next fortun- derful collection of slides. In his patient manner he enjoyed the administrative and intellectual chal- insisted, sometimes quite firmly, on the continu- lenges and was a vice president from 1983 to ing value of many “old-fashioned” virtues: lis- 1985, delighting in the ceremonial. He was tening to the patient, careful clinical examination, appointed Director of Orthopedics at St. Thomas’ and an understanding of the biological processes Hospital in 1972, and was Honorary Treasurer of of disease and repair. Many of his interests, the British Orthopedic Association from 1972 to however, were wider. He skied and was an 1977 receiving the rare distinction of Honorary accomplished pianist, continuing to play in small Fellowship in 1985, having delivered the Robert chamber groups to the time of his last illness. Jones lecture in 1978 and the Watson–Jones His final and richly deserved honor was the lecture in 1984, appropriately enough on “Sur- award of the Honorary Medal of the Royal geons and Writers. This was Alan Apley became the editor of The Journal established in 1802 for “liberal acts or distin- of Bone and Joint Surgery in 1984, at the age of guished labours, researches and discoveries emi- 70 years, with undiminished energy and firm nently conducive to the improvement of natural views on standards and presentation. They Jones, Lord Webb Johnson, Lord Brock, and Sir were always encouraging, never unkind; some Stanford Cade. In his own quiet way, Alan Apley authors, delighted with his response, discovered fully deserved to be added to this distinguished only at their second read that their work had not list. His other great skill was the ability With the death of Alan Apley on 20 December to edit a muddled or ugly sentence into clear 1996, the orthopedic world lost one of its best- prose. Under his kindly editorship, authors felt known and best-loved teachers and writers. For happy to submit their work; there was a steady over 50 years, in an unassuming and often self- increase in the number of submissions and the effacing way, he used his skills in communication beginning of the now firmly international content to help and to guide the expansion of orthopedic of the Journal. He maintained a clear After retiring again, at 75 years of age, he view of the essentials, viewed each advance in the increased his teaching and writing activities. In light of his experience, and always emphasized 1990, for example, he gave instructional courses a hands-on, clinical and caring approach to or major lectures in 11 countries. Throughout his life he engaged in dis- became ill in autumn 1996, his aim was to be fit tilling the important facts from the mass of new for a teaching visit to Australia planned for spring information and then presented them in clear and 1997. He knew that he had unique gifts of expression His eldest brother John, a distinguished pedia- and presentation, but rarely explained and never trician, died before him. A second brother, Martin, mentioned the hours of hard work, the patience lives in London. His son Richard and his daugh- and the dogged persistence that had produced ter Mary, from his first marriage to Janie, have such results. His insistence on the “drawer” both inherited his interest and skill in music. His method of writing papers and lectures was not second wife, Violet, brought great joy into his theoretical; his own work was always put away later years, supported him in his travels and cared for later review and polishing, many times.

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