By M. Murak. Saint Francis College, Brooklyn Heights, New York.
The popular discussion of the role of lifestyle factors in predisposing women to breast cancer compounds women’s worries about their future with guilty reflections on their past behaviour serophene 100 mg online. This is encouraged by epidemiological surveys which report the loosest of associations as causal influences serophene 100 mg with visa. Thus the risk of breast cancer appears to be increased in women who have no children or who have them after the age of 30; in women who have taken the oral contraceptive pill or hormone replacement therapy; in women who drink alcohol and have a high fat diet discount 25 mg serophene with mastercard. The relatively strong influence of family history on chances of getting breast cancer provides further scope for recriminations about genetic destiny and fatalistic ruminations about dying a premature and disfiguring death serophene 50 mg discount. During breast awareness week, a patient of mine who has survived mastectomy, radiotherapy and chemotherapy and now has a good prognosis, came in to ask me what she had done to deserve breast cancer. I don’t know who benefits from breast awareness, but I know many of its victims. Carrying on screening Despite all the problems of the cervical cytology and mammography programmes, the demand for more screening tests for other cancers continues to rise. One of the main sources of such demands in the late 1990s was the burgeoning men’s health movement, associated 62 SCREENING with the wave of men’s magazines, one of the publishing successes of the decade. Though it lacked the early radical impulse of feminism, the men’s health movement adopted the later preoccupation of some feminists with health as their model. Far from challenging medical authority, men’s health promoters urged men to submit themselves to it on a greater scale than ever before. In choosing campaigning issues, 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. Though prostate cancer is relatively common in older men (95 per cent of 15,000 cases a year occur in men over 60), 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.
His ability was recognized by his mem- from many countries—not a few of international bership in the leading orthopedic societies in the renown order 25mg serophene with mastercard. A dinner was held at Manchester Uni- country and in his executive positions in them order 25mg serophene otc. He versity on the evening of Tuesday October 7 buy cheap serophene 50mg on-line, was a student and a teacher purchase 100 mg serophene with amex, occupying the 272 Who’s Who in Orthopedics professorship of orthopedic surgery in his Alma Mater, the University of Buffalo, for nearly 25 years. Numbered among his friends both in his personal and professional life was a noticeable number of young men. None could be more appreciative of the strength or more understanding of the weakness in men than he. Always kind, understanding, and helpful, he was at all times a gentleman. He served in World War I and during World War II he was called as a civilian consultant. There was no activity in his career that he enjoyed as much as this assignment. He continued in this capacity with great sacriﬁce to his practice and to his health. Plummer’s contributions to orthopedic surgery were largely in his teaching and his care of patients. He was not a proliﬁc writer, but the Alfonzo POGGI value of his writings was in their merit rather than 1848–1930 volume. Modern orthopedic surgery lost one of its Alfonzo Poggi was chief of the surgical clinic in strongest proponents when William Ward Bologna at the time he presented the classic Plummer died, February 16, 1953. His 75 years paper: “Contribution to the Radical Treatment of had been well spent, but he paid no heed to them; Congenital Unilateral Coxo-Femoral Disloca- he died a young man, regardless of his time of tion. He was young in spirit, young in venture, and journal, at least the ﬁrst referred to in the main- young in enthusiasm. He died disgusted with his stream of orthopedic literature in which surgi- physical inﬁrmities, because they interfered with cal correction of a congenitally dislocated hip his mental activities. Nourse lectured in anatomy and surgery at Barber– Surgeons’ Hall and at London House in Alders- gate Street. For these lectures Pott dissected demonstration specimens and laid the foundation of the anatomical knowledge that later gave him so great an advantage over his contemporaries. After apprenticeship to Edward Nourse, on “September 7, 1736, Percivall Pott was admitted to the Freedom of the Company (of the Barber–Surgeons) by service, upon the testimony of his master and was sworn. Percivall Pott was examined touch- ing his skill in surgery in order to have the Great Diploma. His answers were approved, and he was ordered a Diploma under the seal of the Company and the hands of the Governors testifying his skill and empowering him to practise. Pott took a house in Fenchurch Street, into Percivall Pott is perhaps the best-known English which he moved with his mother and her daugh- surgeon of the pre-antiseptic era. A few years later he eighteenth century has persisted and been main- moved to Bow Lane and while practicing there tained by clear descriptions of the injury and dis- took the livery of the Barber–Surgeons’ Company eases of bone that are associated with his name. In 1745, he was In him is to be seen the beginning of an attitude elected assistant surgeon to St. Bartholomew’s untrammeled by irrational obedience to the dic- Hospital, becoming full surgeon 4 years later. Company was dissolved by Act of Parliament He was born on January 6, 1714, in Thread- after a partnership of 200 years. The house was subse- separating, the surgeons met together at Station- quently pulled down and on its site an extension ers’ Hall as “The Master, Governors and Com- of the Bank of England was built. His father, a monality of the Art and Science of Surgery,” descendant of an old Cheshire family, died when which body afterward became known as the Cor- he was only 3 years old, leaving a wife and poration of Surgeons. In 1751, they settled in their child in somewhat straitened circumstances. Pott took a very mother, anxious about the boy’s education, active part in the affairs of the new Corporation received help from her relative, Dr. Wilcox, and on July 5, 1753, its Court of Assistants elected Bishop of Rochester, and Percivall was thus sent him and William Hunter as the ﬁrst Masters (or to a school at Darenth in Kent.
The joint space was increased when comparing it to before the surgery and was maintained at ﬁnal follow-up anteroposterior radiographs cheap serophene 50 mg mastercard. Relationship between extent of viable area of femoral head after operation corre- sponding with acetabular roof 50mg serophene overnight delivery, recollapse buy serophene 25 mg line, and progressive joint space narrowing Conventional AP radiographs (n = 48) Total Group A Group B Group C Recollapse 4 (8%) Progressive joint space narrowing 9 (19%) Table 4 order 50mg serophene visa. Relationship between stages, recollapse, and progressive joint space narrowing Stage Recollapse Progressive joint space narrowing 3B 3/40 hips (8%) 7/40 hips (18%) 4 /8 hips (12%) 2/8 hips (25%) Posterior Rotational Osteotomy in Femoral Head Osteonecrosis 95 With regard to the range of motion, in hips without recollapse or joint space nar- rowing, the ﬂexion angle was 60° to 130° (mean, 100°), and abduction angle was 15° to 40° (mean, 22°). Hips with either recollapse or joint space narrowing evidenced ﬂexion from 40° to 100° (mean, 96°) and abduction from 5° to 25° (mean, 19°). Clinical evaluation according to the Japanese Orthopaedic Association hip score system was 84 to 100 points (mean, 91) in hips without recollapse or 50 to 83 points (mean, 67) in those without joint space narrowing. Two hips were revised with a total hip arthro- plasty around 15 years after surgery. Causes of the unsuccessful results including early failure were postoperative inadequate viable area under the weight-bearing portion below the acetabular roof in 3 hips, vascular impairment by operation in 2, and living bone that fractured after a high level of activities in 2, degenerative change in 2, and challenging procedure in 1 because of the young age of the patient. Discussion Several kinds of procedures for joint preservation of femoral head osteonecrosis appear to be effective in early-stage and small or mid-sized necrosis [1–3,12]. Joint preservation of femoral head osteonecrosis with extensive and collapsed lesions in young patients may be an important challenge for orthopedic surgeons. The principal concept of femoral osteotomies for joint preservation in the treatment of femoral head osteonecrosis is that necrotic focus is moved away from the major weight- bearing portion on the acetabulum [2,4,7]. However, many young patients have extensive lesions that do not indicate anterior rotational osteotomy is suitable. Our previous reports of posterior rotational osteotomies including “high degree posterior rotation” [7,8] for femoral head osteonecrosis with extensive lesions showed good results even if patients have extensive lesions and apparent collapse. In the present study, recollapse was prevented in cases with adequate viable area corre- sponding to the acetabular subchondral roof on conventional anteroposterior radio- graphs and 45° ﬂexion on anteroposterior views. In these cases, the anterior viable area can be moved to the loaded portion by the use of the posterior rotational oste- otomy, including the “high degree posterior rotation osteotomy” as described. The extent of the viable area corresponding to the weight-bearing portion below the ace- tabular roof on conventional anteroposterior radiographs was almost equivalent to the extent on the 45° ﬂexion anteroposterior radiographs. Containment and congru- ency between the femoral head and the acetabulum was improved not only in the neutral position but also in ﬂexion of daily activities after this posterior rotational osteotomy. Extended joint space and remodeling of the acetabular subchondral shape were noted in hips with degenerative changes preoperatively. A regaining of the spherical contour of the collapsed femoral head was also found. The authors assumed that the main causes of failure with recollapse were inadequate viable area under the weight-bearing portion below the acetabular roof, fracture of the viable bone with mechanical weakness after a high level of activities too soon after the opera- tion, or vascular damage caused by the operation. In conclusion, posterior rotational osteotomy including the high degree posterior rotation appears effective for the treat- ment of nontraumatic and posttraumatic osteonecrosis of the femoral head with col- lapse and extensive involvement in young patients. The authors believe that this operation may delay the progression of degeneration if adequate viable area can be placed below the loaded portion of the acetabulum. Remodeling of the collapsed lesion and the degenerative acetabular subchondral roof might be one of the impor- tant factors for preserving the joints. Kerboul M, Thomine J, Postel M (1974) The conservative surgical treatment of idio- pathic aseptic necrosis of the femoral head. Mont MA, Fairbank AC, Krackow KA et al (1996) Corrective osteotomy for osteone- crosis of the femoral head. Urbaniak JR, Coogan PG, Gunneson, EB, et al (1995) Treatment of osteonecrosis of the femoral head with free vascularized ﬁbular grafting. Sugioka Y (1978) Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip. Sugioka Y (1980) Transtrochanteric rotational osteotomy of the femoral head.
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