Many children have mystery maladies purchase diabecon 60 caps visa, and the solutions to them must be sleuthed out in the same man- ner as for their adult counterparts order 60caps diabecon visa. Some will require the participation of a pediatric pathologist to help you identify your child’s illness cheap diabecon 60 caps on line. Others are simply a matter of tracking the origin of symptoms and creating a detailed enough picture of the mys- tery malady that any pediatrician—or even you purchase diabecon 60 caps without prescription, the parent—can identify. Here’s how the Eight Steps to Self-Diagnosis helped in four cases: eleven-year-old Jessica, eight-year-old David, four-year-old Lourdes, and nine-year-old Justin, each of whom had a different condition. Because their caring and diligent parents and doctors worked through the Eight Steps, each of these children is now a diagnostic success story. Case Study: Jessica Jessica was a red-haired, freckle-faced sixth grader who loved school and especially loved playing the flute in music class. Around Thanksgiving and quite out of the blue, Jessica began to complain of joint pains and stiffness. Her symptoms were worse in the mornings and on some of those mornings, 187 Copyright © 2005 by Lynn Dannheisser and Jerry Rosenbaum. These days were random, but Jessica’s mom, Marsha, knew just how sick her daughter was when it also happened on music-class mornings. On those days, Jessica would sometimes remain in bed until midday when she finally felt well enough to get up. There was just one problem: by the time she arrived at the doctor’s office, Jessica appeared normal. Jessica must have visited her pediatrician six times over a two-month period, and each time her doctor could find no physical evidence of a prob- lem. Finally, he suggested a referral for what he called “attention-seeking behavior. Nevertheless, she followed the doctor’s suggestion and took her daughter to a mental health counselor “just in case. The other possible diagnosis he suggested was a “school phobia,” where a child complains of pains on the morning of or night before school and con- sequently has a poor attendance record. In these cases, the pains usually resolve after the school bus has left. He reported that he didn’t know the underlying reasons for this yet, which would require further sessions to determine. Marsha thought all of this was utter nonsense since her daugh- ter loved school and wouldn’t miss her flute classes unless she truly felt sick. So Marsha took Jessica to a new pediatrician who couldn’t find any- thing on physical examination either and suggested that perhaps the girl had growing pains—recurrent limb pains that occur during a growth spurt. When he explained these growing pains usually occurred at night, Jessica herself spoke up and told the doctor her pains were worse in the morning. The doctor commented that this would suggest an arthritic condition, but Does Your Child Have a Mystery Malady? He repeated her blood tests and they were consistent with the earlier findings. She began having spiking temperatures and joint swelling, different from the stiffness that was described earlier. These symptoms became very confusing: Jessica’s temperature might spike as high as 103°F, but it would always quickly return to normal again. The doctor found this to be extremely odd and suggested Marsha might not know how to take her daughter’s temperature. This was highly offensive to the concerned and responsible mother of three. She went to the drugstore anyway and purchased three different types of thermometers, including an expensive deluxe digital thermometer and an ear thermome- ter. All this was to no avail—Jessica’s temperature was indeed spiking and measured the same on all three thermometers. The second new symptom was a salmon-colored rash that appeared mostly on her chest whenever her fever spiked. At one point, Marsha marched her daughter into the doctor’s office while she was experiencing one of her fever-and-rash episodes and insisted the doctor see these symptoms for him- self.
No doubt diabecon 60 caps without prescription, their political outlook influenced their style of practice discount diabecon 60caps with visa, but most patients would have scarcely been aware of where to place their doctor on the political spectrum discount diabecon 60 caps without a prescription. Systematic government interference in health care has since eroded the boundary between politics and medicine buy diabecon 60caps fast delivery, substantially changing the content of medical practice and creating new divisions among doctors. Thus, for example, the split between fundholding and non-fundholding GPs in the early 1990s loosely reflected party-political allegiances as well as the divide between, on the one hand, suburban and rural practices, and on the other, those in inner cities. Despondent at the wider demise of the left, radical doctors turned towards their workplaces and played an influential role in implementing the agenda of health promotion and disease prevention, and in popularising this approach among younger practitioners. Allowing themselves the occasional flicker of concern at the victimising character of official attempts at lifestyle modification, former radicals reassured themselves with the wishful thinking that it was still possible to turn the sow’s ear of coercive health promotion into the silk purse of community empowerment. Reflecting the wider exhaustion of the old order throughout Western society, an older generation of more conservative and traditional practitioners either capitulated to the new style or grumpily took early retirement. In 1987 I co-authored The Truth About The Aids Panic, challenging the way in which the ‘tombstones and icebergs’ campaign had grossly exaggerated the dangers of HIV infection in Britain, causing public alarm out of all proportion to the real risk (Fitzpatrick, Milligan 1987). Though the central argument of this book was rapidly vindicated by the limited character of the epidemic, it received an overwhelmingly hostile response, particularly from the left. Radical bookshops either refused to stock it or insisted on selling it with an inclusion warning potential readers that it might prove dangerous to their health. In public debates I was accused of encouraging genocide and there were demands that I should be struck off the medical register. My argument that safe sex was simply a new moral code for regulating sexual behaviour provoked particular animosity from those who took the campaign’s disavowal of moralism at face value. Not only does moralism not need a dog collar, in the 1990s it was all the more effective for being presented through the medium of the Terrence Higgins Trust, once aptly characterised as the Salvation Army without the brass band. Given the pressures of full-time general practice, intensified by the various government reforms and campaigns, this project took rather longer than intended and, in 1996. This was rejected by the Department of Health on the grounds that the proposed project was not ‘in the interests of medicine in a broad sense or otherwise in the interests of the NHS as a whole’. The fact that I was obliged to carry on working on this project in the interstices of the working day has meant that it has taken rather longer than anticipated. This has, however, enabled me to take into account the accelerated development of some of the trends of the early 1990s in the period since New Labour’s electoral triumph in 1997. The scope of government intervention in personal life through the medium of health has expanded—into areas such as domestic violence and parenting—and it has become more authoritarian— notably in the programme for maintaining heroin users on long-term methadone treatment. Yet the remarkable feature of New Labour’s public health initiatives is that they have provoked virtually no criticism either from the world of medicine or from that of politics, from any part of the political spectrum. The collapse of both the old left and the new right gives New Labour unprecedented authority to push forward both its authoritarian public health policy and its ill-considered programme of ‘modernisation’ in the health service. Whatever the fate of Tony Blair’s subordination of the NHS to electoral expediency, it is time to expose the deeper processes of the medicalisation of life and the corruption of medicine. In relation to my earlier dispute with the Department of Health, I would like to acknowledge the support of Diane Abbott, Mildred Blaxter, Gene Feder, Michael Neve, Peter Toon and Tony Stanton. In relation to this book, I am especially grateful to Mary Langan for assistance in many areas and to my medical colleagues Matthew Bench, Tricia Bohn, Gabriella Clouter, Chris Derrett, Janet Williams and Fayez Botros. Thanks are also due to Toby Andrew, Jennifer Cunningham, John Fitzpatrick, Liz Frayn, Heather Gibson, John Gillott, Sally Goble, James Heartfield, Brid Hehir, Gavin Poynter, Mark Wilks. I am particularly thankful to Mick Hume, the x PREFACE courageous editor of LM magazine, where many of the ideas developed here first appeared. I also pay tribute to all the staff and patients at Barton House Health Centre to whom this book is dedicated. Michael Fitzpatrick April 2000 xi GLOSSARY OF ACRONYMS ADHD Attention Deficit Hyperactivity Disorder Aids Acquired Immune Deficiency Syndrome ASH Action on Smoking and Health BMA British Medical Association BMJ British Medical Journal BSE Bovine Spongiform Encephalopathy (aka Mad Cow Disease) CHD Coronary Heart Disease CJD Creutzfeldt-Jakob Disease (also nvCJD: new variant CJD) CMO Chief Medical Officer DHSS Department of Health and Social Security DoH Department of Health ETS Environmental Tobacco Smoke (inhaled by passive smokers) GMC General Medical Council GP General Practitioner HIV Human Immunodeficiency Virus ME Myalgic Encephalomyelitis (aka Chronic Fatigue Syndrome) NHS National Health Service NICE National Institute of Clinical Excellence PHA Public Health Alliance RCGP Royal College of General Practitioners RCP Royal College of Physicians RCPsych Royal College of Psychiatrists UNICEF United Nations Children’s Fund WHO World Health Organisation xii 1 INTRODUCTION We live in strange times. People in Western society live longer and healthier lives than ever before. There is a widespread conviction that the modern Western diet and lifestyle are uniquely unhealthy and are the main causes of the contemporary epidemics of cancer, heart disease and strokes. The fears provoked and sustained by an apparently endless series of health scares, backed up by government and public health campaigns, tend to encourage a sense of individual responsibility for disease.
Today buy diabecon 60caps otc, intermolecular forces can be calculated from a knowledge of the distribution of electron clouds associated with the molecules cheap 60 caps diabecon visa. The characteristics of colloidal particles order 60caps diabecon fast delivery, as described by Shaw buy discount diabecon 60 caps, are somewhat different to those of a molecule, yet the same basic forces operate. The generalised interaction between identical spherical colloid particles dispersed in a solvent depends on the nature of the particles and the solvent and varies with the distance between the particles. Interestingly, and independent of the nature of the particles, it turns out that there is always an attractive interaction between such identical parti- cles dispersed in a solution. This attractive interaction tends to induce aggregation and thus, colloidal dispersions are inherently thermodynami- cally unstable. If an organism can synthesise a colloidal dispersion, either through aggregation of dissolved minerals or polymerisation of self-assem- bled molecules, the formation of the colloidal crystals such as those present in some spore walls (Figure 6. This simple thermodynamic picture is substantially altered if we introduce dissimilar particles into our dispersion. The various interactions now depend on the nature of the two particles, relative to the solvent, and can either favour dispersal or aggregation. Again, this could be the basis for a natural control mechanism; as the number and composition of the col- loidal building blocks evolve, subtle changes in the interactions could switch a dispersion from stable to unstable. The overall interaction between colloidal particles in solution some- times includes two further terms, an electrostatic term arising through the presence of charged groups on the surface of the particle or a steric term resulting from the presence of polymers adsorbed onto the surface of the particles. Several mechanisms lead to surface charge – dissociation of ionic groups, adsorption/desorption of potential determining ions and other ionic materials such as surfactants. The presence of surface charges induces a re-distribution of nearby ions; like-charges are repelled and unlike-charges attracted. Combined with their thermal motion, this leads The secret of Nature’s microscopic patterns 103 Figure 6. Schematic potential energy curve describing the interactions between colloidal particles. The overall potential is a sum of an electrostatic repulsive term which arises due to any charged groups on the surface of the particle and the attractive van der Waals term. When two such diffuse layers overlap, a repulsive interaction is introduced. If the ionic strength is substantially higher, the double-layer interaction is sufficiently reduced and it can no longer provide stabilisation against the van der Waals driven aggregation. In con- trast to the van der Waals interaction which falls off reciprocally with dis- tance, the electrostatic repulsion falls off exponentially with distance. Consequently, the van der Waals interaction dominates at small and large distances, whilst the double-layer interaction dominates at intermediate distances. GRIFFITHS The maximum in the potential corresponds to the barrier to aggregation – the inherent stability of the dispersion. If this barrier is larger than the thermal energy kT, the dispersion will be stable. The polymer layers, however, also introduces new contributions to the overall interaction between the particles. As two particles approach one another, compression of the polymer layer may occur which is unfavour- able. Associated with this compression, is an increase in the local polymer concentration – this can be favourable or unfavourable depending on the solubility of the polymer. If the polymer layers increases the stability of the dispersion, it is denoted ‘steric stabilisation’. The polymer must fulfil two key criteria; (i) the polymer needs to be of sufficient coverage to coat all the particle sur- faces with a dense polymer layer, and (ii) the polymer layer is firmly attached to the surface. How this is engineered is beyond the scope of this article, but the consequences of not satisfying these criteria are informa- tive in understanding the effect that polymers have on the overall interpar- ticle interaction. Since complete or incomplete coverage of the particles results in very different properties (i. The presence of insufficient but very large polymers can also reduce the stability.
We’re getting patients who’ve had a stroke right out of hospital discount diabecon 60 caps otc, and we’re getting a cou- ple weeks of visits purchase diabecon 60caps online. At least you have something on paper to tell the case manager so you can hopefully go back diabecon 60caps, but the patient hasn’t benefited from that OT visit purchase diabecon 60 caps. As Stan Jones, a health policy expert in chronic- disease care, saw it (personal communication, 6 February 1998), From the insurers’ standpoint, services like rehab, physical therapy, and occupational therapy are suspect. Payers, both public and private, are convinced that there’s enormous overuse of services going on. But I’ll bet much of this goes back to practices that have, in fact, gone on with rehab centers and hospitals and clin- ics who are trying to raise revenues anyway they can to pay for the cost of complicated patients whose insurance is inadequate. Admittedly, providers learn to shade the literal truth, trying to protect patients from what they see as foolish regulations. I was working with one of my patients on helping her with safety, going outside, being mobile, walk- ing on level ground. To be reimbursed by Medicare for home care, patients have to be homebound, and therefore you cannot write that you’re taking her outside. The note didn’t reflect the reality because we didn’t want her to lose her reimbursement. This claim has been rejected, and since that bill went to Blue Cross, I’ve had four more sessions. In the absence of more meaningful criteria as to what therapy is appropriate and what’s not, it’s a gatekeeper to cut down on abuse of the system. There’s been a lot of over-provision of rehab services, and there’s been a reaction against that. The professions have been unwilling to police them- selves, and now they’re paying the price for that. In this context, the obvious question is who’s looking out for the pa- tient. It’s harder to count patients’ mobility difficulties than mounting dol- lars spent on their care. Little objective evidence supports the value of these services, as an Institute of Medicine committee reported, The investment in these expenditures is expected to be outweighed by the economic, social, and personal benefits accrued from getting people back to work or school and living independently. Unfortu- nately, very few studies have adequately examined the extent to which rehabilitation achieves these goals—and the relationship of achieving these goals to costs. In today’s climate of rising health care expenditures and emphasis on cost-containment, it is incumbent on the rehabilitation community to demonstrate what works best and at what cost. He believes that scientific evidence about the benefits of rehabilitation is strong in selected areas, notably care following strokes. In most fields of health care, not just rehab, we have less evidence than we really need to make evidence-based decisions. They often feel—and their therapists concur—that they are more likely to maintain their gains if they are in a long-term rehabilitation program.... Once a patient has reached a plateau, once he is not making further progress, he is no longer eligible for services” (1995, 198). Marcia, in her mid thirties, has recently “been nursing a rotator cuff injury”—an injury in her shoulder joint caused by self-propelling her manual wheelchair. She wants an ultralightweight wheelchair, but it is more expensive than the standard heavier model, and her health insurer will not cover it. But you don’t know how it feels, so you end up buying something that may not work out for you. The insurance company won’t apply that $1,200 and let me pay cash for the extra. They’re protecting the disabled person because the wheelchair manufacturer is going to talk you into a more expensive, light- weight chair. Presumably to stymie unscrupulous vendors, Medicare precludes people from paying cost difference themselves, at least for now: “You must accept the chair they are willing to buy, or they will not cover you” (Karp 1998, 27).
