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This rare condition was only recognised as a distinct entity in 1954 buy 20 mg levitra professional amex, in the context of the general decline in infant mortality generic levitra professional 20 mg with mastercard, and the move towards closer scrutiny of deaths at different stages in the first year of life (Armstrong 1986) cheap levitra professional 20mg amex. A diagnosis of SIDS was only accepted as a cause of death for certification purposes in 1971 buy levitra professional 20 mg on-line. The figures vary according to how the condition is defined and rely on the dubious accuracy of death certificates. It has long been recognised that these deaths result from a variety of causes, including a significant, though intensely disputed, proportion from infanticide (Green 1999; Meadow 1999; Emery, Waite 2000). There is no explanation for the danger to babies of sleeping on their front and it seems a highly improbable cause of death. This theory also fails to explain apparent seasonal variations in cot death and the significantly higher incidence among boys. Another theory—that cot deaths resulted from the inhalation of toxic fumes arising from chemicals applied to babies’ mattresses —enjoyed a brief flurry of publicity before being discredited (Limerick 1998). The main effect of the cot death campaign was to raise parental awareness of a rare condition and to intensify their anxieties about their babies’ health. I have talked to several parents who have watched their babies through the night, carefully turning them over on to their backs whenever they rolled over, lest they find them dead in the morning. I have not met parents whose smoking has been blamed for their baby’s death, but the cot death campaign must have compounded their feelings of guilt and pain. In 1995 the Health Education Authority launched its ‘Sun know how’ campaign, followed up in 1996 with the slogan ‘Shift to the shade’. The Australian advice ‘slip, slap, slop’—slip on a shirt, slap on a hat, slop on some suncream—has been widely adopted as part of the sun awareness crusade in Britain. Schools have been a particular target as children are advised to play in shaded areas, wear Legionnaire-style hats and long-sleeved shirts. Though public anxieties are focused on malignant melanoma— moles which turn cancerous—in fact these are a relatively rare type of skin cancer and the one least related to sunlight. They account for less than 10 per cent of skin cancers, around 4,000 cases a year in Britain. These commonly arise in areas of the body not much exposed to the sun, such as the back of the legs, soles of the feet, scalp and buttocks and they are as common in Japan, where sunbathing is not customary, as they are in the West. Though if diagnosed early and treated aggressively, most are curable, some cases are highly malignant and spread early to other parts of the body, resulting in a significant mortality (around 1,500 deaths a year). According to Newcastle dermatologist Sam Shuster, the dramatic increase in the number of ‘suspicious’ moles removed and sent for microscopic examination over the past decade has been paralleled by a tendency to reclassify benign disease as malignant (Shuster 1992). His conclusion is that ‘melanomas are being invented, not found’ and that the resulting ‘spurious cures’ are being ‘used to justify an incompetent and frightening screening programme’. Shuster’s colleague, Jonathan Rees believes that there is ‘no robust evidence to defend most health promotion in this area’ (Rees 1996). The Pill In October 1995 the government’s Committee on the Safety of Medicines wrote to all doctors and pharmacists alerting them to the dangers of an increased risk of blood clotting disorders (venous thromboembolism) associated with seven named brands of contraceptive pills. These, so-called ‘third generation’ pills had been 17 HEALTH SCARES AND MORAL PANICS introduced in the 1980s because they had a lower incidence of side- effects than earlier preparations. It subsequently emerged that, though there was an increase in the relative risk of these pills, compared with earlier pills, the risk was still half of that of thrombosis in pregnancy. In absolute terms, the risk of dying from thrombosis in any of these circumstances in any one year was around one-third of that involved in playing football (3 fatalities per 100,000). My dominant memory of this scare was of a twenty minute discussion about the different risks of different pills with a young woman, who then announced that she smoked twenty cigarettes a day (which is around two hundred times more of a threat to life than any contraceptive pill). The immediate consequence of the pill scare was that many women either stopped using the pill or switched to alternative—less effective—methods of contraception. The slightly longer-term consequence was an increase in pregnancies, resulting, according to an authoritative estimate, in around 12,400 additional births and 13,600 additional abortions in 1996 (Furedi 1999). The resulting extra expenditure on maternity and abortion provision was estimated at a total of £67 million. The ‘human form of mad cow disease’ In March 1996, health secretary Stephen Dorrell announced in parliament that, in the absence of any alternative explanation, the most likely cause of the first ten cases of what became known as ‘new variant’ Creuzfeldt Jakob Disease (nvCJD) was exposure to beef products contaminated with Bovine Spongiform Encephalopathy (BSE) (Fitzpatrick 1998).

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Bartholomew’s Hospital purchase levitra professional 20mg, Pott was the first to introduce regular teaching of 274 Who’s Who in Orthopedics clinical surgery at the bedside levitra professional 20 mg without a prescription. He spoke of cures cheap levitra professional 20mg fast delivery, Pott sometimes referred to safe levitra professional 20mg, was a strong instance of the mistakes and experience of other patients with great advantage of preventing the insinuation of air into similar disorders and such instruction drew many the wound of a compound fracture; and probably would students around him, some of whom included not have ended so happily, if the bone had not made its exit, or external opening, at a distance from the frac- John Hunter, Abernethy, Blicke and Earle. He ture; so that, when it was returned into the proper place, also gave lectures in his own house in Watling a sort of valve was formed, which excluded air. Thus Street, to which he had removed from Bow Lane, no bad symptom ensued, but the wound healed, in some and the attractive manner of his delivery was tes- measure, by the first intention. Bartholomew’s Hospital, he wrote a paper— pound fracture up to the mid-Victorian era, Pott “An Account of Tumours which rendered the himself contributed greatly to the preservation of Bones Soft”—which was published in the Philo- his limb and the good healing of his fracture by sophical Transactions. After that contribution he his foresight in safeguarding the leg from the was silent for 12 years, but at the age of 43 an moment of the accident until he reached his home. It was in 1756, while riding in manuscripts of his lectures, but had published what is now known as the Old Kent Road, that an none of them. Sir James Earle, his son-in- imposed by convalescence in preparing for pub- law and biographer,3 relates that: lication and, once started as a writer, continued writing for over 20 years. His first work—“A He was thrown from his horse, and suffered a com- Treatise on Ruptures”—appeared in 1756, fol- pound fracture of the leg, the bone being forced through lowed by several others on diseases of the testi- the integuments. Conscious of the dangers attendant on cle, head injuries, curvature of the spine with fractures of this nature, and thoroughly aware how lower limb palsy, fractures and dislocations. Pott’s Fracture He sent to Westminster, then the nearest place, for two Chairmen to bring their poles; and patiently lay on the One of the important contributions to surgery by cold pavement, it being the middle of January, till they Pott was his monograph entitled “Some few arrived. In this situation he purchased a door, to which General Remarks on Fractures and Dislocations,” he made them nail their poles. He opposed the existing treat- caused himself to be laid on it, and was carried through ment by continuous instrumental traction, which Southwark, over London Bridge, to Watling Street, near St. I cannot forbear fracture could be best reduced and correction remarking, that on such occasions a coach is too fre- maintained by keeping the limb in such a posture quently employed, the jolting motion of which, with the that the muscles were continually relaxed. This unavoidable awkwardness of position, and the diffi- teaching had a far-reaching effect, for Pott’s culty of getting in and out, cause a great and often a method of treating fractures was generally fatal aggravation of the mischief. At a consultation of adopted in England and it prevailed for several surgeons, the case was thought so desperate as to generations. Pott, convinced that the fracture–dislocation of the ankle that now no one could be a proper judge in his own case, bears his name, with an illustration of the result- submitted to their opinion; and the instruments were ing valgoid-displacement of the foot and a actually got ready, when Mr. Nourse, who had been prevented from coming sooner, fortunately entered the drawing of the skeletal injuries responsible for it. After examining the limb, he conceived there His ascription is quite impersonal and he makes was a possibility of preserving it: an attempt to save it no mention of the fracture that he himself was acquiesced in, and succeeded. In consequence there has been some 275 Who’s Who in Orthopedics misapprehension as to the nature of Pott’s acci- vertebrae. His classical description of the ankle frac- origin elsewhere in the body: the disease was ture–dislocation, and his reticence about his own scrophula, and was capable of revealing itself in fracture of the tibia at a higher level, have misled a variety of organs. To give it a modern termi- many to believe that in describing the ankle injury nology, tuberculosis is an infective disease with he was speaking of something within his own inti- local manifestations. This misconception has helped The treatment of spinal disease had been to fasten his name to the fracture–dislocation. This was a new departure Palsy of the Lower Limbs which is frequently in treatment and was the first sign of understand- found to accompany a Curvature of the Spine and ing of the natural process of cure by osseous is supposed to be caused by it. But he was per- in 1779 and was translated into French and Dutch; suaded, partly by the inspiration of Hippocratic the disease that it described became known on the teaching, to form an artificial sinus by applying continent as “La maladie du Pott. He seemed confirmed in his view patients with their symptoms and signs with so by the frequent relief of paralysis in patients sub- sure a touch that we can add nothing to the mitted to this operation. He differentiated between flaccid and the object of draining an abscess, and indeed there spastic paralysis and noted that spasticity was the seldom is any superficial abscess in Pott’s para- invariable rule of spinal cord pressure in spinal plegia. The artificial sinus imposed recumbency, and in consequence of prolonged rest the paraly- The disease of which I mean to speak, is generally sis disappeared.

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What personal characteristics do I have which might help me to complete my research? Think about your personal characteristics purchase 20 mg levitra professional overnight delivery, likes and dis- likes buy cheap levitra professional 20mg, strengths and weaknesses when you’re planning your research trusted 20mg levitra professional. If you’re very good with people you might like to think about a project which would involve you con- ducting in-depth interviews with people who you find fas- cinating generic levitra professional 20mg free shipping. If you absolutely hate mathematics and statistics, steer clear of large survey research. Or do you prefer to hide yourself away and number crunch, or spend hours on the internet? All of these personal characteristics suggest a leaning towards certain types of research. As you read this book you will find ideas forming – jot these down so that you can refer to them later when you come to plan your research. If your research is to be employment based, the chances are you will have work experience which you’ll find useful HOW TO DEFINE YOUR PROJECT / 3 when conducting your research project. This is valid ex- perience and you should make the most of it when plan- ning your research. Even if your project is not employment based, all of you will have other skills and experience which will help. For example, if you have been a student for three years, you will have developed good literature search skills which will be very useful in the re- search process. Some of you may have developed commit- tee skills, organisation skills and time management expertise. Think about your existing skills in relation to your proposed project as it will help you to think about whether your knowledge, experience and skills will help you to address the problem you have identified. Many research projects fail because people don’t take en- ough time to think about the issues involved before rush- ing to start the work. It is extremely important to spend time thinking about your project before you move on to the planning stage. Through careful thought you should stop yourself wasting time and energy on inappropriate methods as your research progresses. Consider the follow- ing example: EXAMPLE 1: JAMES James wanted to find out about students’ experiences of housing in his university town. When the replies started to come in, he realised that the questionnaires weren’t generating the type of information in which he was interested. When he talked through his concerns 4 / PRACTICAL RESEARCH METHODS with his tutor, it emerged that James was really inter- ested in attitudes towards, and experiences of, rented accommodation. His questionnaire had been poorly de- signed and was not generating this type of information. He had to scrap the questionnaire and construct an- other which he combined with a number of one-to- one interviews to get more in-depth information. He had spent three months designing and administering a questionnaire which had not produced the type of infor- mation he required. If he had spent more time thinking about the research, especially coming to terms with the difference between qualitative and quantitative research, he would have saved himself a lot of time and energy (see Chapter 2). THE FIVE ‘WS’ When you start to think about your research project, a useful way of remembering the important questions to ask is to think of the five ‘Ws’: X What? Once you have thought about these five ‘Ws’ you can move on to think about how you are going to collect your data. One of the hardest parts in the early stages is to be able to define your project, so much research fails because the researcher has been un- able to do this. If you are unable to do this, the chances are your research topic is too broad, ill thought out or too obscure.

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This transmission to other bones safe 20mg levitra professional, accompanied by provided a complete partition between nose and potential articular changes purchase 20 mg levitra professional visa. He was profoundly mouth buy levitra professional 20 mg lowest price, but the new soft palate was often too rigid dissatisfied with the poor level of attainment to play an efficient part in speech 20 mg levitra professional otc. He attrib- has long since been superseded by the procedures uted much of this unsatisfactory state to the lack of plastic surgery, whereby there is secured a of intelligent interest in fractures, particularly in mobile lip, by the use of skin grafts, and a long adhering to traditional splints that failed of their freely movable soft palate. It was said to have started an epoch, for the rigid internal splint has inspired Wilfred Trotter in his planning of similar had an application in orthopedic surgery beyond operations for excision of carcinomata of the the dream of its originator. He maintained that the aged 34 years with oblique fractures of tibia and assumption of the erect attitude favored down- fibula, inserting binding screws. These wired a fractured patella, obtaining osseous bands produced kinks of the bowel at various union, a result rarely obtained by external splint- points and so led to chronic intestinal stasis, ing. Notwithstanding the success of the operation, thereby facilitating infection of the upper alimen- he was submitted to some unfavorable criticism 185 Who’s Who in Orthopedics for this “unjustifiable procedure. The campaign neck into the femoral head, thereby anticipating involved press and platform propaganda, which the later nailing operation. In his hands the operation was per- In 1908 Lane was elected to the council of the formed under strict asepsis, but some other sur- Royal College of Surgeons; he served for 8 years. He was elected a Fellow rather than the manner in which it was performed. In 1913 Lane was made a baronet; some years later he became a Companion of the Bath and a Chevalier No-touch Technique de la Légion d’Honneur. Lane soon realized that if the operative treatment In appearance he was tall and slim with a dis- of fractures was to be safe, a rigorous aseptic tinguished bearing; his face pale, strong and technique was essential. The skin over a wide area handsome with the head slightly inclined to the was prepared several hours before the operation; right. He was on the table the part was painted with a solution twice married, first in 1884 to Charlotte, daugh- of iodine. The operation area was surrounded by ter of John Briscoe, with whom he celebrated his a generous supply of sterile mackintoshes clipped golden wedding, and in 1935 to Jane, daughter of to the skin. The knife used for incising the skin was of whom married members of the staff of Guy’s discarded and a fresh knife employed in the Hospital and the other achieved distinction as an wound. The theater sister held an instru- a leading part in the advance of surgery soon after ment with forceps when handing it to the opera- the antiseptic system was established. He was one tor and she threaded needles with the aid of two of the first to proceed from the antiseptic method pairs of forceps. And he actually control of the fracture, Lane devised pairs of pow- pioneered the perfection of aseptic surgery by erful bone forceps with long handles, which kept introducing the no-touch technique. No part of of operating and his metallic internal splint have an instrument that entered the wound was allowed had a profound influence upon bone and joint to touch the surgeon’s hand. This scrupulous no-touch technique nary dexterity and imbued them with enthusiasm was a byproduct of Lane’s fracture work, but it for surgery. References Lane retired from the active staff of Guy’s in 1920 but continued to practice from his house at 1. Lane WA (1883) Cases of Empyema in Children maintained that disease was due to defective diet Treated by Removal of a Portion of Rib. In 1926 he founded the New Hospital Reports 41:45 186 Who’s Who in Orthopedics 3. Lane WA (1887) A Remarkable Example of the pathologist Erwin Uehlinger, professor of pathol- Manner in which Pressure-Changes in the Skeleton ogy at the University of Zurich, were significant. His intention was to continue his career in phys- Journal of Anatomy and Physiology 21:385 iology, but work in field hospitals during 4. Lane WA (1890) Two Cases of Subdural Abscess Resulting from Disease of the Antrum and Middle Finland’s war against the Soviet Union from 1941 Ear. Lane WA (1893) On the Advantage of the Steel in surgery and orthopedics at the Helsinki Uni- Screw in the Treatment of Ununited Fractures. Lane WA (1894) A Method of Treating Simple surgeon until 1956, although his interest was in Oblique Fractures of the Tibia and Fibula more Effi- the study and treatment of diseases of the muscu- cient than those in Common Use. Transactions of the Clinical Society of London 27:167 loskeletal system.

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An outline on the board or on a transparency showing your teaching plan is a good way of 23 doing this generic levitra professional 20mg with visa. Such visual material will take attention away from yourself 20mg levitra professional sale, give you something to talk to and allow you to settle down buy generic levitra professional 20 mg online. Writing the plan on the board gives students a permanent reminder of the structure of your session 20 mg levitra professional sale. It is good practice to arrive early and chat with some of the students to establish their level of previous knowledge. Alternatively, you can start by asking a few pertinent questions, taking care that this is done in a non- threatening manner. Should you establish that serious deficiencies in knowledge are present you must be flexible enough to try and correct them rather than continue on regardless. Varying the format You should now give attention to the body of the large group session. A purely verbal presentation will be ineffective and will contribute to a fall-off in the level of attention. You should therefore be planning ways of incorporating some of the techniques described in the next section. No more than 20 minutes should go by before the students are given a learning activity or before the teaching technique is significantly altered. Ways of doing this include posing questions or testing the students, generating discussion among students and using an audiovisual aid. The last things that you say are the ones the students are most likely to remember. This will be the opportunity to reiterate the key points you hope to have made. You may also wish to direct students to additional reading at this time, but be reasonable in your expectations and give them a clear indication of what is essential and why it is essential as opposed to what you think is merely desirable. A couple of minutes near the conclusion to allow them to consolidate and read their notes is a worthwhile technique to use from time to time. Rehearsal and check Some of the best teachers we know find it very helpful to rehearse or to try-out some parts of their teaching so this may be even more important for the less experienced. However, the purpose of the rehearsal should not be to become word perfect, and it is impossible to rehearse the outcomes of activities you give your students. A rehearsal will often reveal that you are attempting to cram too much into the time and that some of your visual aids are poorly prepared or difficult to see from the rear of the theatre. The value of a rehearsal will be much enhanced if you invite along a colleague to act as the audience and to provide critical comments and to help you check out projectors, seating, lighting, air conditioning, and other physical matters. In some institutions you will have access to courses on teaching methods. It is likely that one component of the course will give you the opportunity of viewing your teaching technique on video. The unit running the course may also provide an individual to come and observe your teaching, giving you the expert feedback you may not always get from a colleague. Some personal considerations about anxiety when teaching large groups When you are satisfied that you have attended adequately to the kinds of things discussed above, you will find it 25 helpful to reflect on some matters of personal preparation for your teaching. Paramount among these considerations is dealing with nervousness - both before and during your large group session. Most teachers, speakers and actors confess to feeling anxious before ‘going on-stage’. However, if you are thoroughly prepared, much of the potential for nervous- ness will have been eliminated. And you should keep in mind that a certain level of anxiety is desirable to ensure that you perform well! One writer on higher education, Christine Overall, has described the commonly experienced anxiety in terms of ‘feeling fraudulent’. She suggests a way of managing this feeling is to act as if you know what you are doing, and to display the confidence and authority to do what you need to do. In the large group session, this may mean looking at the audience, smiling, handling audiovisual equipment con- fidently, being very clear and firm about instructions for active learning tasks, knowing what you will say and do at the beginning and ending of your session, and so on. Apart from being thoroughly prepared, there are a number of ‘do’s and don’ts’ to keep in mind.

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