By E. Kafa. Cleary University. 2018.
In response to the antigen requires a specific three-dimensional configuration is antigen that has called it forth cheap 25 mg imipramine otc, the antibody wraps its two exploited in the design of some vaccines discount 50 mg imipramine mastercard. These vaccines con- combining sites like a “lock” around the “key” of the antigen sist of an antibody to a region that is present on a so-called combining sites to destroy it buy generic imipramine 50mg line. Antigens such as toxin molecules recognize An antibody’s mode of action varies with different types the receptor region and bind to it discount imipramine 75mg on line. With its two-armed Y-shaped structure, the anti- region is already occupied by an antibody, then the binding of body can attack two antigens at the same time with each arm. This is mainly due to the establish- an antibody surrounds a virus, such as one that causes ment of the various chemical bonds and interactions between influenza, it prevents it from entering other body cells. The visible clumping of the antibody-antigen Another mode of action by the antibodies is to call forth the complex seen in solutions and diagnostic tests such as the assistance of a group of immune agents that operate in what is Ochterlony test is an example of the irreversible nature of the known as the plasma complement system. This function is presently overextended in reacting and then removing them from the body. There are five different antibody types, each one having The presence of antibodies can be detected whenever a different Y-shaped configuration and function. They are the antigens such as bacteria or red blood cells are found to agglu- Ig G, A, M, D, and E antibodies. It is the chief tion, or where there has been a stimulation of the plasma Ig against microbes. Antibodies are also used in laboratory its removal by other immune system cells. It gives lifetime or tests for blood typing when transfusions are needed and in a long-standing immunity against infectious diseases. It is number of different types of clinical tests, such as the highly mobile, passing out of the blood stream and between Wassermann test for syphilis and tests for typhoid fever and cells, going from organs to the skin where it neutralizes sur- infectious mononucleosis. This mobil- By definition, anything that makes the immune system ity allows the antibody to pass through the placenta of the respond to produce antibodies is an antigen. Antigens are liv- mother to her fetus, thus conferring a temporary defense to the ing foreign bodies such as viruses, bacteria, and fungi that unborn child. Or they can be dust, chemicals, After birth, IgG is passed along to the child through the pollen grains, or food proteins that cause allergic reactions. But some of Antigens that cause allergic reactions are called aller- the Ig will still be retained in the baby from the placental trans- gens. A large percentage of any population, in varying mission until it has time to develop its own antibodies. It is an antibody that pro- the body or a blood transfusion that is not of the same blood vides a first line of defense against invading pathogens and type as itself. It is There are some substances such as nylon, plastic, or found in large quantities in the bloodstream and protects other Teflon that rarely display antigenic properties. While they have basic similarities, nonantigenic substances are used for artificial blood vessels, each IgA is further differentiated to deal with the specific component parts in heart pacemakers, and needles for hypo- types of invaders that are present at different openings of the dermic syringes. Practically everyone reacts to certain chemicals, for combines five Y-shaped units), it remains in the bloodstream example, the resin from the poison ivy plant, the venoms from where it provides an early and diffuse protection against insect and reptile bites, solvents, formalin, and asbestos. Viral invading antigens, while the more specific and effective IgG and bacterial infections also generally trigger an antibody antibodies are being produced by the plasma cells. For most people penicillin The ratio of IgM and IgG cells can indicate the various is not antigenic, but for some there can be an immunological stages of a disease. In an early stage of a disease there are response that ranges from severe skin rashes to death. The presence of a greater number of IgG Another type of antigen is found in the tissue cells of antibodies would indicate a later stage of the disease. If, for example, a kidney is transplanted, the antibodies usually form clusters that are in the shape of a star. These are called human leukocyte T-cells to help them in location of antigens. Research contin- antigens (HLA), and there are four major types of HLA subdi- ues on establishing more precise functions of this antibody.
In choosing campaigning issues cheap imipramine 25 mg with amex, they proceeded by analogy with the feminists: they had cervical smears—we demand prostate examina- tions; they can do breast self-examination—we can feel our testicles order imipramine 25 mg with amex. Though prostate cancer is relatively common in older men (95 per cent of 15 order imipramine 50mg online,000 cases a year occur in men over 60) order imipramine 75mg without a prescription, testicular cancer is a rare disease of younger men (causing around 100 deaths a year). Though treatment is often effective for both cancers, screening tests for early detection are generally considered unreliable. To detect prostate cancer it is possible to have a regular digital rectal examination, a blood test for the Prostate Specific Antigen, and a local ultrasound scan, but the predictive value of all these tests is low. Urologist Peter Whelan suggested that ‘Promotes Stress and Anxiety’ was an accurate description of the effect of the blood test. Given the rarity of testicular tumours, a high rate of false positive results is the inevitable outcome of any promotion of self- examination (Austoker 1994b). It is however striking that, long after medical authorities have accepted the ineffectiveness of screening tests like the PSA, or self- examination of breasts and testicles, pressure groups and popular magazines continue to promote them. The extent of popular approval of these techniques, which is grossly disproportionate to any value they might have in reducing the impact of cancer, is a potent indicator of the pathological preoccupation with health that now prevails in society. It is ironic that young women are often advised to examine their breasts every month—an arbitrarily selected frequency that happens to coincide with the menstrual cycle — though the large majority of women with breast cancer are post- menopausal. Similarly, young men now turn up at the surgery after reading about prostate cancer in their men’s magazines and request screening for a condition that only rarely appears before retirement age. The parallel between screening tests for cervical and prostatic cancer is symbolic. Just as the smear test exposes women not merely to the medical gaze but to vaginal penetration, so the palpation of the 63 SCREENING prostate involves digital penetration of the male rectum. The slippery finger may be less impressive than the metal speculum, but it is no less significant as an instrument of symbolic domination. Rejecting the evidence of the ineffectiveness of mammography, Delyth Morgan of Breakthrough Breast Cancer insisted that ‘what we should be debating is how best to screen women’ (Guardian, 7 January 2000). This response provides striking confirmation of the observation made fifteen years earlier in another critique of screening: ‘In “keeping the faith”, screening advocates may find themselves forced to accept or reject evidence not so much on the basis of its scientific merit as on the extent to which it supports or rejects the stand that screening is good’ (Sackett, Holland 1975). The danger of this approach is not only that it leads to the continuation of costly and ineffective programmes. It also means that the harms of screening are passed over in silence: to mention them could discourage people from taking up the offer of testing. Indeed this was the first concern of the cancer charities in response to reports of the Danish study of mammography quoted above; public reassurances about the quality of the national cervical screening programme accompany every exposure of poor standards. Yet the harms resulting from screening are substantial: for every woman who benefits, tens of thousands undergo testing and hundreds receive unnecessary treatment. In presenting screening as an unequivocal benefit to women, doctors become advocates of state policy rather than of their patients’ interests. State intervention in personal life In the screening programme the author was assigned an ‘adviser’ who would ‘help her with her health’ on an ongoing basis and monitor her progress towards ‘better health’. The extensive questionnaire Taking the first step to better health’ included the tendentious and extraordinarily patronising statement that the screening ‘has been devised to help you change the way you look after your health. The author took umbrage at (a) the assump-tion that she was not healthy already, and (b) the assumption she didn’t know how to look after herself… 64 SCREENING The questionnaire also included a ‘Women’s section’ of questions from the banal to the intrusively, impertinently and offensively intimate to ‘help her with her health’. The author objected and was told that she was unusual in questioning the questions (most women, apparently don’t because they trust doctors and have been brainwashed into believing that they need this nonsense). Over the past twenty years there has been, in the name of health promotion, a dramatic increase in state intervention in the personal life of the individual—ironically in a period when the state has been inclined to withdraw from economic and social commitments. The immediate consequence has been a stricter regulation of individual behaviour, though because this has been justified in the cause of improving the health of both the individual and the nation, it has not generally been experienced as coercive. The changed relationship between the state and the individual that is reflected in the greatly enhanced role of health has also changed the role of the medical profession and has given rise to a range of new institutions and professionals working in the sphere of health promotion. The origins of each of the lifestyle interventions we have examined lie within the world of medicine and its attempts to tackle the ‘modern epidemics’ of heart disease and cancer. However, as is clear from our brief survey of the development of these interventions, at a certain point each was taken up by the state and transformed into a major national initiative. In the case of smoking, this occurred with the shift of focus to passive smoking in the late 1980s; in relation to CHD, government promotion of ‘healthy eating’ began earlier but also became a major campaign in the late 1980s and in the Health of the Nation initiatives of the early 1990s; both the cervical and breast screening programmes were nationalised in 1987–88. The state’s assumption of a leading role in health promotion inevitably changed the character of these initiatives.
Nor did they pause to reflect that these international conferences were ready to approve radical resolutions because these resolutions had no practical consequences buy imipramine 25 mg cheap. The key theme of the new public health movement was the need to shift the focus of health promotion from the level of the individual to tackle the wider social determinants of ill health (and unhealthy behaviour) imipramine 75 mg overnight delivery. The first triumph of the new public health took place at a conference organised jointly by the WHO and UNICEF in Alma Ata in what was then the Soviet Union in 1977 order imipramine 25mg mastercard. This conference adopted a declaration calling for ‘Health For All’ order imipramine 75 mg amex, to be achieved ‘by the year 2000’ through a comprehensive programme amounting to the reconstruction of the world according to socialist principles of redistribution and 79 THE POLITICS OF HEALTH PROMOTION equality. In 1985 the European office of WHO adopted a set of 38 targets against which progress of different national governments towards the goals of ‘Health for All’ could be measured. The ‘new public health’ made further advances the following year, when a conference in Ottawa endorsed the movement’s emphasis on the ‘empowerment’ of communities to take the initiative in matters of health promotion away from governments and professionals. A further conference in Lisbon brought together new public health activists engaged in ‘healthy city’ projects organised by local councils, around the themes of ‘equity in health’, ‘community participation’, ‘partner-ships for health’ and ‘inter-sectoral collaboration’. A number of critics have exposed the curious combination of utopian fantasy and cynical rhetoric that characterised the new public health movement. While activists projected a vision of revolutionary social transformation, it was only as employees of (decidedly moderate) government agencies that they had any prospect of implementing their health promotion policies. The Australian sociologist Deborah Lupton accurately identified a contradiction in the movement’s conception of ‘empowerment’: if someone who is more powerful ‘empowers’ someone who is less powerful, their relationship is still didactic and paternalistic (Lupton 1995:60). In a similar vein, Sarah Nettleton argued that the ‘fallacy of empowerment’ was revealed by the fact that health promotion was invariably oriented towards the least powerful people in society (Nettleton 1995:238). A number of commentators noted the origins of the ‘healthy cities’ projects in ‘paternalistic and cynical’ ‘community development’ programmes developed by the British colonial office in the 1950s to contain potential unrest, suggesting that establishment concern about preventing inner city revolt after a series of riots in the early 1980s provided the impetus behind community health initiatives (Farrant 1991; Peterson, Lupton 1996). Critics also focused on the potential for discrimination and containment that lay behind concepts of ‘community’. They observed that ‘participation’ often had a token character, which co- opted people into the existing power structure while giving them no real power in making decisions. Thus, while espousing a rhetoric of radical social change, in practice the activists of the new public 80 THE POLITICS OF HEALTH PROMOTION health operated as professionals implementing government policies of an essentially conservative character. While delegates to conferences in exotic international locations endorsed revolutionary declarations, supporters of the new public health at home sought to use these as a lever to press the government into adopting similar policies. A number of domestic influences, emerging more or less directly out of the experience of the previous Labour government, also encouraged the new public health movement. The first was the controversy over ‘health inequalities’ that ran through the 1980s—and remains an issue under New Labour today. In response to growing concern among radical social policy academics about increasing income differentials and their impact on health under the Labour governments of the 1970s, in 1977 health minister David Ennals set up a working group chaired by Sir Douglas Black, president of the Royal College of Physicians. By the time the group had completed its report—in April 1980—the government had changed and Mrs Thatcher was so hostile to the report’s call for a redistribution of resources and a re-orientation of health services to tackle the problems of poverty that it was effectively suppressed (Black 1980). The resulting furore ensured an even bigger readership when The Black Report was briskly published by Pelican (Black 1982). It was re-issued in 1988, together with an extensive update by Margaret Whitehead and an introduction by two members of the original working group, as Inequalities in Health (Townsend, Davidson 1988). The issue of increasing inequalities in income and in indicators of health became a rallying cause for radical critics of the Conservative government in the 1980s, keeping ministers under pressure to bring forward some initiative in this area. In the course of the 1980s a number of influential individuals and agencies encouraged the development of the government’s health promotion policy. The chief medical officer Donald Acheson produced a report recommending an enhanced role for ‘public health doctors’ and also endorsed the WHO approach to monitoring progress in public health by setting targets (Acheson 1988). In 1985 the Kings Fund and the Health Education Council organised a ‘study tour’ to investigate health promotion in North America; a team closely identified with the new public health issued an enthusiastic endorsement of the WHO strategy on their return (Robbins 1987). The following year another multi-disciplinary committee sponsored by the Kings Fund, with the brief to chart progress since Owen’s 81 THE POLITICS OF HEALTH PROMOTION Prevention and Health in 1976, produced a report with the suggestive title The Nation’s Health (Smith et al. This report also welcomed the WHO declarations and chastised the British government for its tardiness in meeting these targets. In its discussion of priority areas, strategies and targets, lifestyles and preventive services, it closely anticipated both the form and substance of the Health of the Nation documents.
Others may contribute to the pathology generic 25 mg imipramine with amex, such as toxic effects of phenytoin on the cerebellum discount imipramine 25mg with amex, a presumed site of pathology in PME generic imipramine 50mg with amex. For those who treat many patients with epilepsy 50mg imipramine overnight delivery, the greatest obstacle to treating myoclonus is applying the goal of monotherapy. In the more severe and chronic forms of myoclonus, monotherapy is seldom effective, and patients may require three or more medications. In progressive disorders, a mere 20% clinical improvement is considered a good response and may be functionally signiﬁcant. Polytherapy still carries attendant risks for oversedation and drug–drug interactions, but it is a reality in myoclonus therapy. Table 2 Antiepileptic Drugs for Myoclonic Disorders Antimyoclonic Unstudied Sometimes promyoclonica Often promyoclonica b Clonazepam Clobazam Gabapentin Carbamazepine Ethosuximide Eterobarbb Lamotrigine Oxcarbazepine Felbamate Remacemideb Lorazepam Phenytoin b b Levetiracetam Stiripentol Pregabalin Phenobarbital Tiagabine Vigabatrinb Primidone Topiramate Valproic acid Zonisamide a In epileptic patients. However, it is important to choose antiepileptic medications for their antimyoclonic potential as well. This usually means removing phenytoin and carbamazepine-like drugs and replacing them with clonazepam, valproate, primi- done, or other antimyoclonic drugs. Occasionally, a patient will have a history of sta- tus epilepticus when such changes are attempted and we leave their regimen alone. Development of tolerance is a signiﬁcant problem in the treatment of myoclo- nus regardless of the speciﬁc agent being used. Caution is indicated when the dose of clonazepam is increased due to tolerance, as choking on secretions may result at higher doses in individuals with PME. Weight gain on valproate, an important drug for EPM1, can be massive in wheelchair-bound patients. Co-administration of a very small dose of topiramate may offset this effect. Nonantiepileptic Drugs Nonantiepileptic drugs as a group are the second line of symptomatic therapy for myoclonus, often reserved for special circumstances (Table 3). The pharmacologic treatment of autoimmune myoclonus serves as an example of therapy unrelated to AEDs or other neuropsychotropic drugs. Opsoclonus–myoclonus syndrome is best treated with immunotherapy, such as corticotropin (ACTH), intravenous-immunoglobulins (IVIG), or chemotherapy. Symptomatic treatments for the sleep disorder and rage attacks, such as trazodone, can be co-administered. Intramuscular injection of botulinum toxin temporarily alleviates painful seg- mental myoclonus. In preventing the release of acetylcholine at the neuromuscular junction, botulinum toxin may block involuntary movement but will preserve strength. The effects last from weeks to months, but the injections can be repeated. The current trend is toward lower doses than those recommended initially. Table 3 Non-AEDs for Myoclonic Disorders Drug Indication Acetazolamide PMA Baclofen PME Beta-adrenergic blockers Essential myoclonus Chloral hydrate PME Depo-estrogen Perimenstrual exacerbation of myoclonus a 5-Hydroxytryptophan =carbidopa Posthypoxic myoclonus Piracetamb Cortical myoclonus Lisurideb Photosensitive myoclonus Midazolam Opiate-induced myoclonus in cancer patients Trihexyphenidyl Myoclonus-dystonia a A physician may prescribe under the manufacturer’s IND in the United States for this speciﬁc indication only. Myoclonus 155 Nonpharmacologic Therapy Vitamins, cofactors, dietary restriction, and chelation for metabolic disorders are examples of being able to treat myoclonus by reversing the underlying disorder. Together they constitute the most important category of nonpharmacologic therapy. Biotin can reverse the symptoms of biotinidase deﬁciency or other causes of biotin deﬁciency. Implementation of the ketogenic diet early in the course of EPM 2A may bypass a metabolic defect in carbohydrate metabolism. Transcranial magnetic stimulation (TMS) is a noninvasive, safe, and painless way to stimulate the human motor cortex in humans.