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But if it can be shown order zudena in united states online erectile dysfunction treatments vacuum, for example purchase zudena 100 mg online impotence at 37, that spending a dollar on educa The Arguments 3 tion would improve health m ore than spending the same dollar on health services purchase zudena australia erectile dysfunction doctors in utah, or if it could be dem onstrated that diet and nutrition are far m ore im portant to health than any am ount o f curative care generic zudena 100 mg amex xyzal erectile dysfunction, the need for a national health insurance program becomes doubtful. The issues should be o f vital interest to those interested in fiscal austerity and lean governm ent, as well as to those who feel that health is o f the greatest national im portance, irrespec tive of cost. Should we indenture our health in the future to the existing medical care system when better health might be ensured through other means? T he answer should be no; but it is virtually certain that Congress will do so, and with the support of the vast majority of the people. It calls for the dissolution of the largest and most expensive social service system in the world—the medical care system in the United States. The “radical” critique centers first on the exploitation of the hapless consum er by the rapacious provider and, second, on the failure of the “system” to extend services to everyone, in spite o f the alleged exploitation. This analysis is accurate as far as it goes, but it fails to engage the pivotal issue—what does medicine have to do with health? T he radical solution—the provision o f care to everyone— may simply result in m ore care for those who may not need it. But if it is health we care about, and not medical care, we m ust look for im provem ents in the life setting of the unhealthy, not simply the provision of services designed to cure them once they are sick. If this can be done, then a leaner and tougher approach to health can be created out of the remains of the current delivery system. T he new approach will build on 4 Introduction those things that generate health; unlike present-day medicine, it will not rely on profound interventions when health has been lost. T he United States is about to enter into a “contract” with the exisdng medical care deliv ery system by legislating its legitimacy through a national health insurance program. I begin with evidence on the relative impact of personal m edi cal care and a set of socioenvironmental factors. It is here, in C hapter 2, that m uch of the research and literature on the “effectiveness” of medical care is compiled. T hen I turn to a history o f the “crisis” in health care, together with a discus sion o f its evolutionary features, to show where and how it is evolving. Next I turn to some “social futures” for the United States and their implications for health. This is done dialec- tically, by contrasting the evolution of medicine with a pro jection of the future, to dem onstrate the divergence between the medical care system and the larger society of which it is a part. T he end of medicine is coming both because of inter nal contradictions within the present system and because the system does not correspond with an em erging Zeitgeist. In C hapter 6, I attem pt to state what health is, having spent five chap ters spelling out what it is not. In C hapter 7, through a brief historical analysis o f the eras of medicine, I propose some o f the elements of a new paradigm for health. In this last chapter I also resurrect the question of national health in surance, because it is on this question that the public debate about health care will turn. If a comprehensive program of national health insurance is prom ulgated in the next few The Arguments 5 years, as is almost certain, the structure, prerogatives, and style of practice of the existing medical care system will be frozen for decades. If the outcome is simply m ore medical care, our health will be worse and our well-being as a popu lation will be in jeopardy. Finally, in an epilogue I draw the broad outlines o f a new medicine, which must be calibrated with the future and specifically with the health care needs o f the future. Although most of the points are docum ented, the ultimate test is their theoretical strength. T hree characteristics of medical practice are particularly perplexing to the uninitiated. First, determ inations of the quality of care are made with out reference to the actual outcomes of care to the patient. To use a homely example, most of us judge a restaurant on the basis of the taste and quality o f the food. Seldom do we inquire as to the chefs lineage or education, or visit the kitchen to inspect the ovens and utensils. The quality of means and the results of health care are m atters of different im portance and m agnitude, but the analogy fits. Unlike the quality of food, the regulatory measures traditionally em ployed to control the quality of medical care have focused on who renders it and how, m ore often than on what the results have been. T here is one notable exception, although Florence Night ingale should get similar kudos. Codm an, a surgeon at Massachusetts General Hospital, sought to orient assessment o f the quality of medical care from structural or input evaluation—who did it—to process 6 The Impact of Medicine 7 and end-result evaluation—how and why. T he results revealed shock ingly low quality of care; only 89 of the 692 hospitals could meet the standards established for the study. Limited circu lation of the results aroused so much controversy that Cod- man could not at first get his findings published and then could not find sponsors for further research. He argued that patients should be required to pay only for good results, and that people should be aware of the results of their care. This is a slight variation on the practice in Babylon o f severing the physician’s hand if he failed to cure. He published annual reports that docum ented the results of his care and his methods o f accounting for the results. Cod m an concluded that 183 (or 54 percent) were managed without undue complications. For the rem aining 154 cases that were not satisfactorily managed in his judgm ent, 204 separate judgm ents were m ade to determ ine why problems arose. In most cases (roughly 76 percent), the problems were found to be due to errors in physician care, including surgi cal misjudgment, use of faulty equipm ent, or misdiagnosis. Second, and m ore puzzling than the failure of the medical care enterprise to examine its results, is the paucity of re search on the impact of care on the health of populations. Controlled clinical trials have been used to measure the impact of medical cures for individual patients. But, histori cally, with the surrender of medicine to the scientific m ethod, “population” medicine was relegated to the schools of public health, while medicine went to work on the indi vidual. Consequently, we know something about medicine’s impact on individual patients but very little about the impact of medical care on populations. T hird, there is even less research on the relative impact of 8 The Impact of Medicine personal medical care services and other socioenvironmental factors such as education, housing, air, water, seat belts, and Muzak. In other words, other than some anecdotal and impressionistic evidence, we have virtually no inform ation on the relative weight to assign to the various factors that bear on health, including medical care. First, evidence about the outcomes of medical care, when it is presum ed to be efficacious, is examined. T hen the obverse is examined—when the outcomes are adverse as a result of iatrogenesis, or disease “caused” by the medical care system itself. Next, the placebo effect is assessed, followed by a discussion of the im portance o f caring. The balance of the chapter examines the slender research on the impact of medical care on the health of populations and concludes with a review o f the even m ore sparse work on the relative impact o f medical care and other factors on health. To grapple with this subject, the following definitions de veloped by the W orld Health Organization can be used.
The regular quality control procedures include: —Setting up and recalibrating the detector; —Checking the working parameter setting of the device; —Making a phantom study of transmission and emission zudena 100 mg with visa erectile dysfunction heart attack. The less frequent quality control tests include: —After power shutdown: checking detector set-up and normalization; —After servicing: checking detector set-up order zudena overnight delivery impotence pills, performance and normali- zation; —After change of source: checking normalization and making a phantom study; —When necessary: changing the transmission sources zudena 100 mg fast delivery erectile dysfunction performance anxiety. Radiation protection and measurement equipment Any nuclear medicine facility involves the use of radiation in many different ways discount 100mg zudena with visa erectile dysfunction doctor washington dc, including: —Handling, storage and disposal of small to large activities of radioactive material, potentially in gaseous, liquid and solid forms; —Storage and handling of sealed radiation sources; 138 4. As a result, different types of radiation measuring equipment are required as follows: —Passive personnel dosimeters; —Active (direct reading) personnel dosimeters; —Contamination monitoring instruments (photons and beta radiation at least); —Radiation field monitoring instruments (photons). Types of radiation detectors The various types of radiation detector are described briefly below, in particular their advantages, disadvantages and uses, all of which must be understood by the user. It operates by measuring individual radiation events, which can also be smoothed out into a continuous signal of radiation exposure rate. Geiger counters can be calibrated to read in units of absorbed dose or equivalent dose, with, however, limited accuracy. The detector itself is usually in the form of a cylinder of varying size, from 2 cm long by less than 1 cm diameter, to around 10 cm long by 3 cm diameter. The detector may have a thin entry window for more efficient detection of low energy photons and particles. The first two usually have a shield to filter out particles so that only photons are measured. Removing the shield also allows particles to be detected, for example in contamination measurements. End window type detectors can be made very thin to allow beta and even alpha particles with energies greater than about 50 keV to be detected, whereas side window types (with a larger surface area) are thicker and will only allow photons and more energetic beta particles to pass. Pancake type detectors also have a thin window but a larger area, and are designed for contamination measurements. In nuclear medicine, most of the photon and beta energies used are above 60 keV, so the energy limitation is not a major problem. The most versatile and useful Geiger counter for nuclear medicine use should have the following features: —Have a thin window (but with protection against accidental damage) for particle detection; —Have a window shield for discrimination against particles; —Produce an audible signal of radiation events (for contamination detection); —Be calibrated in dose rate units allowing a wide measurement range, say 10 Sv/h to 10 mSv/h; —Be energy compensated to give the lowest possible detectable energy; —Be powered by easily available batteries, or have an inbuilt battery charger. A detachable probe may be of use for contamination measurements, but inbuilt probes will suffice in most cases. Some models have an audible indication of dose rate and/or an alarm which sounds at predetermined steps of total dose. These devices are very useful where staff may be exposed to high levels of radiation, for example, when using 131I for therapy. They are, however, more bulky and expensive than Geiger counters and may not be as rugged. While they (like Geiger counters) measure exposure, they can be calibrated to measure absorbed dose or equivalent dose. They may operate at ambient pressure or be pressurized for higher sensitivity and stability. The use of ionization chambers in larger nuclear medicine departments is justifiable, and they may also be useful in smaller facilities. Proportional counters are used for sensitive radiation detection where energy discrimination is important. Their main radiation safety use is in contamination detectors, which can be set for a particular radionuclide. Scintillation detectors are used for in vitro sample counting, for probes designed for organ counting or surgical exploration and for general counting. Owing to their energy discrimination capability, they are used in some larger nuclear medicine facilities for spectroscopic investigations to identify radionu- clides. These instruments have a very high sensitivity and provide a reading in counts per minute or counts per second. Until recently, the most common type was the germanium detector — an expensive and complicated device used for high resolution photon spectroscopy, and rarely used in nuclear medicine. There are now many miniaturized solid state detectors available as personal dosimeters, with the ability to provide integrated dose, dose rate and dose or dose rate alarms. These devices are affordable and are recommended in situations where staff may be involved in higher radiation level work. They allow direct reading of integrated exposure (or calibrated as absorbed dose), and are simple and cheap. The film badge uses a special type of photographic film in a special holder fitted with filters of various types to allow discrimination between beta and photon (and in some cases neutron) radiation, at various energy levels. As a result, the wearer’s radiation exposure can be estimated as an effective dose. The sensitivity of a film badge varies according to the supplier, but the lower limit of readable dose is of the order of 200 mSv. Cheap, and widely available, film badges still remain an effective means of assessing doses to staff. Radiation monitors A nuclear medicine department needs to have, or have immediate access to, at least one radiation monitor. Instruments may be designed to measure dose rate (in mSv/h), integrated dose (mSv) or contamination level (Bq/cm2). Dose rate measurement is necessary to ensure that levels of radiation in working environments are within the limits required by legislation and also to confirm dose rates from packages that may be despatched from the radio- pharmacy. Suitable monitors may be based on ionization chambers, Geiger– Müller counters, scintillation detectors or proportional counters. The choice of instrument is governed by the nature and level of radiation anticipated in the environment. Contamination monitors are necessary for routine use to detect any spillage of radioactivity that may have occurred. In view of the fact that gamma emitting radionuclides are most commonly used, a monitor based on a scintil- lation detector will be suitable, although in situations where beta emitters are used, a Geiger–Müller counter is also valuable. Quality assurance Any device used for radiation detection must be regularly calibrated, with the calibration traceable to a recognized primary or secondary standard. Any of the types of radiation instruments mentioned above can drift over time to become inaccurate. As far as contamination monitors are concerned, the calibration source must be spread over a known area, and different radionu- clides should be used. Calibration is performed to ensure that the instrument readings are as accurate as possible for the type of instrument concerned. Consistency testing can be performed on a calibrated instrument to check for drift. All that is required is a 137 radiation source that has a reliable output ( Cs for example) and a repro- ducible testing geometry.
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Criticism of Professor Baum had first been raised in an Observer article by Adam Raphael order 100mg zudena overnight delivery erectile dysfunction remedies diabetics. Such conflicts buy zudena 100 mg with mastercard can you get erectile dysfunction age 17, although inherent in the everyday relationship between the physician and the patient 100 mg zudena with amex injections for erectile dysfunction forum, are brought into sharper focus in the circumstances of a drug trial purchase zudena 100 mg otc impotence age 45. In the randomised and blinded trial, one group of patients are, unknown to themselves, given a non-effective treatment, a placebo, while others are given the treatment on trial. A doctor who is completely open and honest with a patient, who gives the full information about the nature of the trial and the drug being used, before obtaining the consent of the patient, is unlikely to be criticised on ethical grounds. However, many doctors and scientists argue that to forewarn a patient about the exact nature of a trial is to reduce its scientific usefulness, increasing the chances of subjective responses distorting the outcome. Drug trials are at the very heart of industrial medicine, and it is at this interface between the loyalty doctors feel to science and industry and the individual patient in need of care, that the most seminal medical conflicts emerge. Trials not only take place in hospitals but are also organised by general practitioners who can give unknowing patients new and unproven drugs. If patients were fully informed, there is a possibility they might refuse to take part in trials. Hard commercial considerations also come into the frame, some patients might take the view that medicine is not a philanthropic affair and by making themselves available for experimentation, they will in the long run help a drug company to make profit. This being the case, they might ask for payment commensurate with risk, or commensurate with the failure to be effectively treated. They might also ask for insurance contracts covering the eventuality of adverse effects or serious mishap. Such an eventuality would put the relationship of the doctor and the patient into a clearly different alignment than presently is the case; it would perhaps be a more honest relationship. The pressure to introduce informed consent and to democratise drug trialing has inevitably opened up a market for agencies which recruit subjects for drug trials on a commercial basis. Governed entirely by commercial contracts, there is the possibility that the work of such trial centres and their recruiting agencies could exploit populations such as students, the unemployed, the low paid and captive populations such as prisoners. It has been estimated that in excess of 10,000 human volunteers were used for drug trials in 1988; they were paid 3 fees of about £2million, by drug companies. Hospitals which opt out of the National Health Service could well consider making a proportion of their money by using their facilities and patients for drugs trials. Spurred on by two deaths in 1984, the Royal College of Physicians produced a report entitled Research on Healthy Volunteers in 1986. Many critics of scientific medicine believe that science and its needs should never take precedence over the rights of the sentient human being. They argue that one of the most fundamental human rights is the right not to be subjected unwittingly to experimentation. Another basic right is that, on turning to a doctor, a sick person should receive the most proven, effective and available treatment. The operation for the removal of a breast is called a mastectomy; one of the surgical alternatives to mastectomy is lumpectomy in which only the tumour and surrounding area is removed from the breast. Shortly after her operation, Evelyn Thomas noticed that the woman in the bed next to her, who had been through a similar operation, was being treated with a different regime. It took Evelyn Thomas four years to find out that she had been included without her consent in a trial, and a little longer to find out the full details of the trial, the treatment she had been given and the treatment she had been denied. The randomised trials of which Evelyn Thomas had been a part were initiated in 1980 by the Cancer Research Campaign, under the auspices of Professor Michael Baum. Translated, this means simply that the trials were looking at supportive treatment following breast cancer surgery. Besides the granting and denial of counselling, two hormonal drug therapies, Tamoxifen and Cyclophosphamide, were given to the different trial groups. The trials involved 2,230 women at thirty hospitals across the country between 1980 and 1985. The progress and condition of one group of women who were given the different treatments singly or in combination with or without the counselling, were compared with the condition and progress of another group who were given no adjunct treatments at all. When Evelyn Thomas read about the results of the trial in 1986, it confirmed her suspicions that she had been part of a randomised trial. I placed absolute trust in those treating me and assumed our relationship was based on openness and frankness. Actually patients at that time had their treatment determined by computer randomisation. My rights to have information and to choose, and my responsibility for 6 my own body were denied. The defence of those who had experimented on Evelyn Thomas without her consent was weak. However, after a nurse counsellor pointed out that some patients became distressed when faced with the uncertainty of having to choose their treatment, informed consent was waived for all trial subjects who passed through the hospital. The trial administrators had been against allowing informed consent but had found themselves compelled to compromise with the Hospital Ethics Committee. The raising of this complex and worrying issue on the eve of an awesome operation, threw most women into a state of immobility and confusion. When the poor results of trial subject selection were brought to the attention of the Hospital Ethics Committee, they withdrew their demand for informed consent. Only six years previously, Baum had entered his patients into the trial without obtaining their informed consent. In the same letter to the Observer, Baum complained that the paper used a photograph of him which made him look like Mussolini. Richmond, who made clear her friendship with Baum, argued in favour of science and randomised clinical trials, while at the same time failing to address the matter of informed consent. When Evelyn Thomas found that she had been used as a guinea pig, she complained to the South East Thames Regional Health Authority. The complaint was dealt with by professional medical and health workers, whose system of complaints investigation makes the Police Complaints Authority look like something from the Magic Roundabout. Her case was reviewed by two assessors, a cancer specialist and a consultant surgeon. The cancer specialist who oversaw the complaint was a close colleague of Baum, and another future member of the Campaign Against Health Fraud, Professor Tim McElwain. Unsurprisingly, the professional review found that Evelyn Thomas had been treated in a correct and professional manner. Despite a number of deaths which have occurred as a consequence of uninformed - - trialing " " throughout the eighties, attempts to change medical research methodology have not been completely successful. It In 1982, an 84 year old widow died after having been involved in a secret randomised trial, in 13 Birmingham. In 1983, another trial patient died; the woman had been reluctant to take part in 14 the trial. Carolyn Faulder accepted the invitation to join the working party, thinking that she could make a real contribution to the debate about informed consent.
Such actively detached people have the capacity and desire to relate socially order 100 mg zudena mastercard erectile dysfunction doctor omaha, but fearing humiliation and disapproval they distance themselves from others 100 mg zudena overnight delivery impotence signs. Differentiation (Millon & Davis buy genuine zudena erectile dysfunction age 30, 2000) Paranoid - believes he is the object of a conspiracy Avoidant - sees himself as ridiculous (but may interpret routine questions as criticism) Schizoid - derives little from interpersonal relationships Avoidants - interpersonal relationships are punishing; prefers advance notice of what others expect 1857 Avoidant cases may have been very submissive when growing up purchase zudena once a day erectile dysfunction treatment in allopathy, or they may have had a longterm physical illness. Therapists may be milked for constant reassurance, especially that he/she will not desert the patient. The therapist must not exploit or encourage submissiveness, or to reject a clingy client. There is a very high comorbidity rate between avoidant personality disorder and social phobia (Pigott & Lac, 2002) leading some authorities to suggest that they are synonymous. Many people are shy right up into adolescence and it may be erroneous to regard them as having avoidant personality disorder. The term ‘narcissism’ was introduced by the English sexologist Henry Havelock Ellis (1859-1939) in 1898. Psychoanalysts then used the term to describe a reaction to damaged self-esteem: ‘narcissistic injury’. These patients are submissive and appeasing in relationships and inhibit negative responses for fear of destroying a relationship. Group therapy may encourage efforts at autonomy by practicing alternative coping styles in a safe setting. Families must be won over so that any changes in the patient are not met with negative responses. One theory is that people with this personality disorder were the victims of excessive rage and humiliation in childhood. However, once interrupted they may view the therapist as unhelpful or unprofessional. Also, the present author is struck by how many ‘house proud’ depressives he has encountered. An essential first step is to develop a (tentative and often brittle) trusting relationship. When psychoanalytic psychotherapy is undertaken it is important for the therapist to take an active stance and to promote a focus on (avoided) feelings and the patient’s need for control rather than engage in endless intellectualisation. It may overlap aetiologically with major depressive disorder but a twin study suggests that it is a distinct entity. F62 is called ‘enduring personality changes, not attributable to brain damage and disease’. There should not have been a previous personality disorder that explains current traits. The change is aetiologically traceable to a profound, existentially extreme experience. Examples include enduring personality change following torture or concentration camp experiences. This phenomenon, known as hardening of the categories, results in overgeneralization and inflexibility". Rosowsky and Gurian (1991) provide the example of prescribed medication misuse replacing earlier self-mutilation in borderlines. Certain factors, like artistic talent, were conducive to a better outcome, while others, such as parental cruelty, were associated with a poorer outlook. Lenzenweger ea (2004) also found considerable variability in features of personality disorder over time. Some forensic issues ‘It seems clear …that it is impossible at present to decide whether personality disorders are mental disorders or not, and that this will remain so until there is an agreed definition of mental disorder’. The commonest diagnoses among convicted murderers in this part of the world are personality disorder, alcohol misuse, and drug abuse. However, without assertive follow up, mentally ill ex-prisoners are prone to lose contact with services, to re-offend and up back in custody. Children of criminals or psychopaths adopted by ‘normals’ are more likely to show antisocial behaviour than the offspring of ‘normals’. Most such children are quickly recovered since there may be no attempt to conceal them. Personality disorder (ill defined with overlap of categories) or psychosis (usually schizophrenia) are common in perpetrators. The act may satisfy an emotional need, may be used to manipulate the environment, or may be impulsive and psychotic. In one study the great majority of those who assaulted their wives had a personality disorder. Objections included 1864 unfairness to the female sex (who may be victimised in relationships and end up with a label ) and possible confusion with depression. It has been suggested that people with masochistic personality disorder become hypochondriacal manipulators when they cannot obtain love and nurturance by other routes: an abusive attachment is better than no attachment. His thinking from viewing masochism as part of a spectrum shared with sadism to one of Thanatos (the masochist wished for self-destruction). In contrast to Freud, Horney, in the 1940s, believed that sadism wasn’t necessarily sexual in origin - that is that personality- based attitudes were bound to manifest themselves at some stage through sexual activity. The aim should be change real life behaviour rather than simply look for change in the treatment setting. Although rotation systems make it difficult, as far as possible the one therapist should continue to see the patient. Millon and Davis (2000) consider the psychotherapies just as good and just as bad as one another when applied to the personality disorders. Efficacy should be subject to ongoing scrutiny and spurious ‘cures’ should be studied critically. Development of a therapeutic alliance and acknowledgement of vulnerability to manipulation by therapists are important ingredients of any therapeutic approach. The evidence-base for many drug-based ‘treatments’ for personality disorder is flimsy. The Dangerous People with Severe Personality Disorder Bill was introduced in 2000 by the British Labour government with the aim of removing people who might commit future crimes from society. Certain prisons and special hospitals are assigned the role of detaining such individuals. There is a feeling of pleasure, gratification, or release at the time of the act, and the act is consonant with the immediate conscious wish of the person, i. Following the act there may or may not be feelings of regret, self-reproach, or guilt. Nidotherapy (changing the person’s environment rather than trying to change the person) and transference-focused therapy (dysfunctional relationships are examined within the transference and the patient is taught to reflect) are some other approaches.