Due to its proximity to the vertebral column gastritis diet ãîãë cheap biaxin master card, it is susceptible to traumatic disruption 319 from compressive or acceleration-deceleration forces gastritis blog buy biaxin 250mg cheap. Although traumatic chylothorax in children has been described after motor vehicle crashes gastritis ulcer disease order cheap biaxin, it is also seen after child abuse gastritis diet soda order discount biaxin online. Traumatic chylothorax usually has a cryptogenic and sometimes delayed presentation gastritis and diet pills biaxin 250mg with visa, because the development of a clinically significant chylous effusion may take up to 24 hours to accumulate gastritis diet õ??õýëäýéí discount 500 mg biaxin visa. In the acute setting of trauma gastritis and constipation cheap biaxin 250 mg without prescription, clinical examination may be similar to pleural injury or hemothorax gastritis vitamin c purchase biaxin on line, with findings of respiratory distress or diminished breath sounds on auscultation. Regardless, evaluation remains unchanged, as these findings should prompt further evaluation with a chest x-ray. The identification of a pleural effusion in the acute setting of trauma is a hemothorax, until proven otherwise. Diagnosis of a chylothorax is established with the evacuation of milky-white pleural fluid. Fluid analysis demonstrating triglycerides levels > 110 mg/dL, lymphocytes > 1000cells/mL, presences of chylomicrons, and low cholesterol levels is confirmatory. Due to its association with non-accidental trauma, further evaluation of the child is necessary for concomitant injuries. Chylothorax can result in respiratory, nutritional, and immunologic compromise, due to losses in the pleural space. Management includes chest tube decompression, dietary modification, and nutritional support. The primary goal of therapy is to decrease chyle flow to allow closure of the disrupted thoracic duct. The patient may be trialed on a low-fat diet consisting of only 320 medium-chain triglycerides, which is absorbed directly into the portal system, rather than the lymphatics. If drainage persists or increases, the patient should be made nothing by mouth and total parental nutrition should be initiated. Octreotide is a long-acting somatostatin analog, which acts directly on vascular somatostatin receptors, may also be considered for adjunctive therapy to decrease lymph fluid excretion. Traumatic chylothorax typically resolves with non-operative management within 10 to 14 days. However, when conservative measures fail, operative ligation of the thoracic duct through thoracotomy or video-assisted thoracic surgery may be necessary. Penetrating Lung Injuries Penetrating wounds occur almost exclusively in teenagers in the pediatric population and account for 10% to 15% of pediatric trauma cases. In comparison to blunt chest trauma, penetrating chest injuries are associated with higher rates of operative intervention and mortality. Stab wounds to the chest should be evaluated for penetration into the thoracic cavity. Suggestive physical exam findings include crepitus in the subcutaneous tissue or active air movement through the wound itself. Placement of a three- sided occlusive dressing over the wound can be a life-saving maneuver and prevents the precipitation of a tension pneumothorax. Fortunately, the majority of stab wounds to the chest in children do not go beyond the muscle wall. Thoracic bullet penetration injuries can result in significant tissue damage from direct missile penetration or secondary missiles from bone fragments. Furthermore, bullets may travel in an unpredictable trajectory, necessitating complete evaluation of intrathoracic structures, including the mediastinum. A chest X-ray is obtained to assess for pneumothorax, hemopneumothorax, or mediastinal air. Tube thoracostomy should be placed for pneumothorax or hemothorax, and a persistent air leak should prompt further evaluation for tracheobronchial tree injury. Operative criteria for bleeding include > 20 mL/kg blood loss on initial tube placement or persistent bleeding at a rate of 3cc/kg per hour. In cases where significant bleeding occurs from a missile tract through the lung parenchyma, a pulmonary tractotomy should be performed. The entry and exit wounds on the lung are first identified, and a penrose drain is subsequently placed through the tract to assist with retraction. A gastrointestinal anastomosis stapler is then placed into the tract and fired to complete the tractotomy. This 322 allows exposure of the injured lung and hemostasis can be achieved with selective suture ligation of bleeding vessels or tissues. The entry and exit wounds should be left open to allow drainage and the suture line should be tested for leak at the end of procedure. Penetrating Injuries to the heart Penetrating injuries to the heart in children are rare. The right ventricle is the most often injured cardiac chamber, followed by the left ventricle, because of their anterior location in the chest. Clinical manifestations of tamponade physiology include tachycardia, hypotension, distended neck veins, muffled heart sounds, and pulsus paradoxus. In unstable patients with hemodynamic compromise, bedside pericardiocentesis or subxiphoid pericardial window can be life-saving, temporizing maneuvers. Regardless of hemodynamic stability, definitive surgical repair for penetrating cardiac injury is necessary. The chest is entered through a left 323 anterolateral thoracotomy or sternotomy, and the pericardium is opened sharply with scissors taking care not to injure the phrenic nerve. Depending on the size of the cardiac wound, a finger may be used to occlude the laceration. Repair is then performed with nonabsorbable mattress sutures over Teflon pledgets. For larger wounds, occlusion of laceration can be achieved by inserting a balloon catheter into the wound and inflating the balloon with saline. Traction on the catheter will stem bleeding temporarily to allow suture repair of the wound. Hemodynamically Stable Thoracic Trauma Pediatric trauma resuscitation begins with a primary survey to assess for life-threatening conditions that demand immediate intervention. Establishing a secure airway is the first priority in trauma resuscitation, followed by breathing and circulation. Although there are levels of prioritization for the primary survey, the patient assessment and execution of care are performed simultaneously in a systematic and expeditious manner. Breath sounds are assessed for symmetry and air movement, and cardiopulmonary monitoring is established as peripheral intravenous access is established. As the patient is quickly surveyed, life-threatening injuries should be identified and addressed accordingly. In a hemodynamically stable patient, once the primary survey is determined to be intact, the exam should then proceed to the secondary survey to sufficiently assess the patient from head to toe for external signs of injury. Physical examination should include auscultation, visual inspection, manual palpation, and percussion of the chest wall. Depending on the mechanism of injury, particularly blunt trauma, the physical exam may not demonstrate outward signs of injury. Therefore, a chest x-ray is indicated if there is a clinical history of a high-risk mechanism for trauma, or if there is any clinical signs of chest injury present on the child. A surveillance anterio-posterior chest X-ray can be obtained without significant difficulty in a supine, immobilized patient. The x-ray should be examined systematically to evaluate for pleural injury, pulmonary contusions, mediastinal abnormalities, and rib fractures. If findings on chest x-ray are inconclusive for hemothorax or pneumothorax, the study can be supplemented with a bedside ultrasound of the chest. Positive findings for pleural injury or effusion warrants management with chest tube thoracostomy. Other chest x- ray findings for thoracic injury, including rib fractures and pulmonary contusions, should prompt admission for pain control and pulmonary hygiene. If rib fractures present or the patient history is not congruent with the patients presentation, social work involvement may be necessary to assess for possible child abuse. Mediastinal abnormalities on chest x-ray or clinical history of high speed acceleration-deceleration traumas warrant further imaging in a hemodynamically stable patient. Computed tomography angiography should be performed in these select cases to efficiently evaluate for aortic, 325 esophageal, or tracheobronchial tree injury. Aortic injuries require admission to the intensive care unit for strict heart rate and blood pressure control. Esophageal and tracheobronchial tree injuries require further endoscopic examination and immediate surgical intervention. Hemodynamically stable patients, who are asymptomatic, without significant mechanism of injury, and negative radiographic findings of intrathoracic injury may safely be discharged. Otherwise, an injured child should be admitted for cardiopulmonary monitoring, pain management, and radiographic reassessment as indicated. Hemodynamically Unstable Thoracic Trauma In a hemodynamically unstable patient with altered mental status or unresponsiveness, the airway should be secured immediately with endotracheal intubation. Verification of proper tracheal intubation may be established with the appreciation of symmetric bilateral breath sounds and appropriate change in the end-tidal carbon dioxide detector. Fluid resuscitation should be initiated with a 20 mL/kg bolus of isotonic crystalloid fluid such as Lactated Ringers or normal saline. If access is not obtained in 2 attempts or 90 seconds, intraosseous access should be obtained without delay. During resuscitation the mechanism of injury and external signs of thoracic injury should be assessed to determine the etiology of cardiovascular collapse. Life- threatening conditions associated with thoracic injuries include tension pneumothorax, massive hemothorax, cardiac tamponade, and cardiac arrest. A patient that has suffered blunt or penetrating chest injury to the chest presenting with hypotension and unilateral diminished breath sounds should be quickly assessed for tension pneumothorax. The trachea is evaluated for midline position and the internal jugular veins are examined for distention. Tension pneumothorax is a clinical diagnosis and treatment should not be delayed for radiographic imaging. If the constellation of signs and symptoms are present and clinical suspicion is high, needle thoracostomy should be nd performed immediately. Introduction of a large bore angiocatheter in the 2 intercostal space, mid-clavicular line to the affected side will evacuate the pleural space of air and alleviate tension physiology. Chest tube thoracostomy is subsequently performed to definitively address the pneumothorax. If the patient is hemodynamically unstable with unilateral diminished breath sounds and does not clinically appear to be demonstrating tension physiology, hemorrhage into the chest may potentially be the cause of shock. If the patient responds to fluid resuscitation, a prompt chest x-ray should be performed to evaluate for a large hemopneumothorax. With initial placement of the chest tube blood will immediately evacuate and the initial output should be noted. Initial volume out of a chest tube that is greater than 20 ml/kg of bleeding, especially if the bleeding persists, may warrant emergent thoracotomy in the operating room to control the bleeding. If tension pneumothorax and massive hemothorax are absent and the patient remains hemodynamically unstable despite appropriate fluid resuscitation, the patient should be evaluated for cardiac tamponade. Confirmation of fluid in the pericardial sac demands emergent exploration in the operating room. In blunt trauma, however, emergent thoracotomy should be avoided as it is almost uniformly futile. Emergency Room Thoracotomy 328 the role of emergent thoracotomy in the pediatric population remains unclear. Prior to 1990, the survival of pediatric trauma patients after an emergent thoracotomy ranged from 0% to 4%. Over the past two decades, only two retrospective studies have since examined the role of emergency room thoracotomy in children. A total of 34 patients were reviewed and only 3 patients (10%) suffering penetration injuries survived. No children who suffered blunt injury and underwent emergent thoracotomy survived in these studies. Despite significant improvements in pre-hospital trauma care by emergency medical response teams and the development of specialized pediatric trauma centers, pediatric survival rates after emergent thoracotomy remain concerningly low. Unfortunately, the infrequency of this procedure in children limits sufficient data to draw definitive conclusions. The paucity of information regarding emergent thoracotomy in children is likely due to the fact that children rarely have cardiac arrest after trauma. Furthermore, when patients do present with sufficient indications for thoracotomy, the procedure may not be performed due to either lack of evidenced based data regarding utility of the procedure in children, or providers may lack appropriate surgical experience to perform the procedure. Although the pediatric literature demonstrates low survival rates after emergent pediatric thoracotomy, it should still be considered as there are no other alternative to death in these patients with critical injuries. Currently, 329 management algorithms are extrapolated from the adult literature and follow the Advanced Trauma Life Support guidelines. The procedure is performed by first prepping and draping the left chest th in the usual sterile fashion. An incision is made at the 5 intercostal space from the sternum to the mid-axillary line. Sharp dissection is carried through the intercostal muscles into the thoracic cavity. The left lung is retracted anteriorly and superior, and the pericardium is examined for pericardial tamponade. The pericardium is incised with scissors anterior and parallel to the phrenic nerve. In the face of severe hemorrhage, the aorta is identified just above the diaphragm. The aorta is then cross-clamped with a large vascular clamp to stem ongoing bleeding during resuscitation. If necessary, the left sided thoracotomy incision may be extended through the sternum into the right chest to fully expose the heart and allow evaluation for right thoracic injuries. Additionally, thoracic injuries are often associated with multi-system involvement. Optimal treatment includes a systematic approach to resuscitation and thorough evaluation for life-threatening injuries. The utility of computed tomography as a screening tool for the evaluation of pediatric blunt chest trauma. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Serum troponin-I as an indicator of clinically significant myocardial injury in paediatric trauma patients. Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Penetrating cardiac trauma in adolescents: A rare injury with excessive mortality. Percutaneous balloon- expandable covered stent implantation for treatment of traumatic aortic injury in children and adolescents. Diagnostic accuracy of ultrasonography in acute assessment of common thoracic lesions after trauma. However, abdominal injuries occur in 10-15% of injured children and continue to lead to significant morbidity and mortality [1]. The most common mechanism leading to abdominal solid organ injury in this population is motor vehicle related accidents. Regardless of the mechanism or organ injured, the pattern of injury does differ in the pediatric population when compared to the adult population. This is due to the differences in anatomic and physiologic characteristics of children when compared to adults. Compared to adults, children have a more compliant abdominal wall and rib cage, as well as less body fat. These factors all contribute to an increased risk for abdominal injury due external forces. Physiologically, children manifest the effects of blood loss much differently than adults, because of their ability to compensate by increasing heart rate and systemtic vascular resistance to compensate for blood loss. In children, hypotension is an ominous sign that suggests impending cardiovascular collapse. Aside from the vital signs and patients condition, facts about the scene of the trauma and mechanism of injury should be elicited. In cases of falls, knowledge regarding the height from which the child has fallen and the surface where he landed lends a sense of the force of impact that he may have sustained. A quick summary of the childs past medical history, allergies, medications, and last meal should be elicited from pre-hospital medical personnel the evaluation of the abdomen during trauma can occur during the primary or secondary survey, depending on the mechanism of injury and the known injuries sustained. Once in the trauma bay, findings on physical exam may give clues as to potential intra-abdominal injuries. In a patient with suspected abdominal injuries, a complete blood count and a metabolic panel are typically obtained. Amylase and lipase are often sent, but some investigators argue that they are reliable or cost effective screening tools [10]. A typical diagnostic uncertainly in a trauma patient is the presence of free fluid without solid organ injury. Fluid in the abdomen may be a normal finding or may suggest bowel injury or may be an incidental finding. In these circumstances, laparoscopy may be utilized common diagnostic adjunct, depending on the clinical scenario.
Mothers are responsible for most of the 75 caregiving and as a result gastritis symptoms with diarrhea order biaxin 500mg on-line, female caregivers are of poor health as compared to male caregivers gastritis otc biaxin 250 mg sale. Furthermore gastritis diet advice nhs biaxin 250 mg fast delivery, caregivers who already suffer from underlying chronic conditions exhibit even poorer 61 health as they have limited time to look at their own personal needs and health gastritis diet cure purchase biaxin online pills. Other stress outcomes of long term caregiving include deteriorating self-concept gastritis diet ideas cheap biaxin 500 mg without prescription, cognitive 59 66 79 problems gastritis diet sample menu order biaxin 250 mg on line, altered self-efficacy and decline in emotional well-being chronic gastritis from stress cheap biaxin 250 mg without prescription. This can lead to difficulties 80 in marital and social relationships as caregivers have constrained social opportunities and limited 28 freedom because of long hours consumed by caregiving atrophic gastritis symptoms treatment order biaxin uk. Further, unpredictable caregiving 61 demands results in stress and anxiety in caregivers and ultimately leads to poor psychological 66 health. The strain of 16 62 caregiving, affects the mothers self-efficacy, and this ultimately affects parenting skills. A study revealed that the strongest predictors in caregivers health in caregiving a child with intellectual disability in Kenyan were: child 72 behaviour, childs temperament, severity of disability, low self-esteem and poor social support. These include physical, social and emotional health and well-being, marital relationships, 28 67 81 and employment and financial status. A meta-analysis by Pinquart and Sorensen revealed that higher age, lower socioeconomic status and lower levels of informal support were related to poorer health of caregivers. Patient status, caregiver status and social factors are the 79 most salient factors related to caregiver burden. Furthermore, they had poorer: social 17 functioning, mental health, emotional health, and generally lower perceived health. Furthermore, perceived severity of disability has been reported to affect the health of the 74 caregiver than the actual disability. Further, there is a great need to design tailor-made interventions to alleviate the 58 burden on caregivers as it ultimately affects the childs functional prognosis and health outcomes. Additionally, caregiver strain in its extreme, can lead to inhumane or cruel treatment or even murder 79 of disabled people by the caregiver thus the need to deal with it. Given the multi-dimensionality of burden of care, there is need to consider multiple strategies to combat the effects of caregiving. Factors affecting buffering ability include: characteristics of the 59 caregiver, caregiver shared history and social, economic and cultural circumstances. Service providers should strategically work on technical issues such as booking schedules i. Health professionals should take into cognoscente that lack of time is cited strongest predictor to 28 62 non-compliance with treatment thus the great need to consult caregivers on booking schedules. This highlights the need for policy makers to look into implementing this model of care. Furthermore, provision of low cost 46 aids would also help to alleviate physical and financial burden in caregivers. Likewise, timely access 70 to therapy and assistive devices can lessen the burden on caregivers. Social support can be 46 informal or formal with informal care is mainly provided by relatives and friends whereas formal 60 support is provided by professionals, home support services and respite care options. Social support is needed and can be offered in various ways for instance 79 emotionally or instrumentally. Furthermore, social interaction and social support are essential if social connectedness is to be achieved. This also entails the involvement of the extended family so as 1 to lessen the burden on the primary caregiver. Palamaro Munsell et al hypothesized that social 19 connectedness mediates caregiver strain thus resulting in improved or positive caregiver well-being and this results in positive child adjustment and family cohesion. The results from their study showed that caregiver well-being is significantly associated with caregiver social connections and 65 caregiver strain. Therefore, health education and promotion in caregivers is essential to encourage 81 46 them to engage in more social activities as this also increases informal support. This 81 70 substantiates the need for professional social and emotional support for caregivers. Educating the caregiver on the disability, stress management and counselling can 1 75 assist in this regard. It is also important to provide responsive respite options and therefore its the obligation of therapists to also provide caregiver with information on the available respite 62 options as health education and promotion are mandatory to therapists. Furthermore, greater caregiver involvement in mental health programs is associated with better functional/treatment outcomes for the child as well as with improved child 85 behaviour and emotional health. Therefore, provision of mental health programs assists caregivers in adjusting thus easing the burden of care. Therefore interventions for caregivers should also 75 focus on improving communication skills. Additionally, improved communication skills increases perception of parental sense of control and improve parenting skills. Therefore, provision of fitness training programs can help in alleviating physical burden among caregivers. Furthermore, motor fitness is associated with a higher self-efficacy in caregivers as it enables them to meet the physical demands 79 of the caregiving role. This can be in form of government grants for children with 1 disabilities and waivers in accessing certain services such as health and education. There is need for national surveillance system for planning and budgeting purposes so as to improve therapeutic 70 outcomes and consequently improving the plight of their caregivers. Firstly, the difference in research settings with most of the research emanating from high-income countries. Further, use of different tools employed with different psychometric properties limits the generalisability and comparability of the studies. Satisfaction in itself is an indicator of the quality of service 8 89 90 91 delivery and it can be used as a clinical audit tool. More so, its essential to evaluate patient satisfaction with services delivery as satisfaction is inter-rated to treatment compliance and 89 92 outcomes. Satisfaction can be defined as the extent to which a program fulfils patients 8 expectations. This drive has been stimulated by the shift towards a client-centred approach, competition for 93 limited resources and the correlation between satisfaction, quality of care and treatment efficacy. There is a paucity of published surveys of patient satisfaction with physiotherapy services in Africa and in paediatric neurology. Evidently, most of the outcome tools were 91 93 95 97 developed for use in private physiotherapy settings. Additionally, most of the respondents 89 91 97 98 were patients with orthopaedic or musculoskeletal problems. This is reflected in diversity of 22 90 91 93 95 97 95 surveys thus have been developed thus far to measure satisfaction. External factors relate to logistical and environmental factors such as the processes of making bookings and the comfort of the waiting 95 area. Therapists friendliness and 91 communication skills have been identified as the most important predictors of patient satisfaction. For instance, availability of 90 93 services and amount of time spent with the therapist. Time spent with therapist is a strong predictor of satisfaction with more time spent during treatment sessions is associated with greater 89 satisfaction. Harding and Taylor (2010), carried out a survey on 165 outpatient physiotherapy and 89 occupational therapy patients at three metropolitan heath sites in Australia. They utilised the MedRisk Instrument for Patient Satisfaction with Physical Therapy and additional two open ended questions. Most of the patients were receiving treatment for musculoskeletal/orthopaedic conditions, and there was a spread of respondents age. Results revealed a very high rate of satisfaction with overall satisfaction of 96%. Furthermore, their results revealed significant high scores on internal items (therapist-patient interaction and treatment-related factors) as compared to external factors (booking process and environment. Patients indicated that the most positive experiences were related to staff attitude, therapist communication and attitude, therapist technical skills, effect of treatment and the process of care. Psychological indices such as perceptions and expectations also affect satisfaction with 90 91 physiotherapy. Patients with extremely high, unmet expectations are more likely to be dissatisfied with services and relationship with therapist and would ultimately tend to change 90 healthcare providers according to the consumer model. Further if patients perceive that interventions by therapists are going to assist them in recovery, they are more likely to be satisfied 90 91 with treatment. The amount of explanation and information given can also have a bearing on patient satisfaction. Having more insight with regards the impairment(s)/health condition and treatment process are 8 90 associated with greater satisfaction. Additionally, continuity of care also affects satisfaction as most patients normally prefer to be treated by the same therapist. This promotes a better patient- 90 therapist relationship and this also assists in the attainment of continuity of care. The booking system affects the waiting times and research reveals the link 89 between short waiting times and patient satisfaction. Therefore, scheduling of treatment sessions 90 in such a way that they fit into the clients schedule affects the level of satisfaction. Furthermore, the comfort of the waiting area also affects patient satisfaction; this is in terms of comfort of the 91 sitting area, decor and lightning. The sample consisted of patients of diverse diagnoses, with orthopaedic patients and the 60-79 age bands constituting the majority of the clients who completed the survey questionnaire. The survey revealed a high satisfaction with physiotherapy services especially in the domains of therapists interpersonal skills and the treatment facilities. Patients expressed the desire to be more involved in the drafting of the treatment plan, more treatment time, being consulted on 93 appointment scheduling and effective communication especially on explanations and instructions. The strengths of this study were in the fact that the survey was designed with input from other clinicians and physiotherapists. Furthermore, the survey was administered by a volunteer and this helped in promoting the honesty of responses by decreasing desirability bias. The data was dichotomised for data analysis, thus presenting the threat of losing data properties by converting data from an ordinal scale to a nominal scale. Their results revealed a very high satisfaction rate with physiotherapy services with an overall 94 satisfaction rate of 83% and a 83-94% satisfaction range for the domains on the questionnaire. They distributed the adapted scale to measure satisfaction with physical therapy to 3960 physiotherapy, occupational therapy and respiratory therapy patients. The scale to measure satisfaction with 24 physical therapy is a validated tool to measure patient with physiotherapy services and was developed in Switzerland. Of note is that, 40% of the questionnaires were completed by close relatives who were more critical as compared to responses given by patients. There were significant differences in satisfaction across the hospital categories except for the reassurance in therapy especially in the domains of quality of information given, explanations on 99 treatment and well as in the feeling of security domain. These are technical assistance, interpersonal relationship and the 91 physical environment. It is essential to consider the patients preferences and working schedule if to 89 enhance satisfaction and compliance with services. All in all, patients who are actively involved in decision-making with regards to their treatment plan are more likely to be more compliant and 91 satisfied with services. Parameters such as the perceived quality of care received and waiting times all affect patient satisfaction. More staffing 89 levels would decrease patient waiting times and this increases patient satisfaction. Furthermore, quality facilities and equipment are essential for delivering quality care. Thus improving on the 93 facilities and acquisition of equipment all work towards improving satisfaction. There is also need to 93 involve the patient in goal setting and treatment progression. A client-centred approach, based on the provision of essential information, empathy and making the patient feel more secure during 99 treatment contributes towards client satisfaction. Additionally, improving on the amount of time spent per client also results in more satisfied 93 patients. However the economic implications of lengthy treatment sessions also need to be considered. Also, offering patients the opportunity to express dissatisfaction or platform to suggest 25 areas of improvement in service delivery can help in improving service delivery and ultimately on 89 improving satisfaction. Thus, 89 the need to improve the waiting area in terms of comfort, lighting among other issues. Even though it has been a subject of research for more than four 105 decades now, its definition and strategies to combat it have remained elusive. Furthermore, given 4 104 105 106 its negative implications on treatment efficacy and strain on resources, there is a great 107 108 need assess it. Complexity of compliance is reflected in the multiple definitions that have been postulated. In the context of physiotherapy, compliance would therefore imply the extent of adherence to prescribed appointments, educational activities, following advice from treating 4 5 physiotherapist and/or a home exercise regimen. Compliance and adherence are used interchangeably in literature 105 and as such, the two terms will be used interchangeably in this text. This variability in non-compliance rates 102 has been partially attributed to a lack of a standardized definition of compliance. It therefore warrants the assessment of compliance with physiotherapy 101 appointments as adherence ultimately affects the efficacy of therapeutic interventions. Literature states that anticipated difficulty in home exercise program is the strongest predictor in 102 103 compliance. This perceived difficulty is also affected by variables such as pain tolerance and 103 109 self-efficacy. In the same vein, highly perceived functional gain and or pain relief is positively 109 correlated to compliance. Personal motivation also affects compliance rates as patients who are motivated are more likely to 109 110 104 105 109 be compliant. Furthermore, perceived efficacy of interventions can also 109 increase compliance. However, a research by Alexandra et al revealed that compliance was not 102 associated with depression or health locus of control in low back pain patients. Complex 112 exercise routines may lead to non-compliance as highly perceived difficulty exercises are 110 associated with high rates of non-compliance. Additionally, the nature of relationship between health-care professional also affects compliance. Therefore, effective communication and a trustworthy relationship are essential in this regard, i. A systematic review on the barriers of adherence in physiotherapy in outpatient states that low in- 103 treatment adherence is a very strong predictor of non-compliance. This reiterates the need for professionals to constantly monitor, provide feedback and assess compliance with prescribed 113 exercises during the treatment sessions. The severity and prognosis of a condition may also affect compliance with treatment. For example, patients with mild back pain are more likely to be compliant as their symptoms may resolve in a shorter period of 102 110 time. Patients may fail to 114 turn up for scheduled appointments because of financial strain. In summary, a survey of Ontario chiropractors to assess their views on the maximization of patient 111 compliance, the following variables were found to be strong predictors of non-compliance : low level of motivation sedentary fitness levels low level of pain tolerance low self-esteem levels 111 inexperience with exercises 2. Non- 104 compliance can lead to delayed progress as treatment outcomes may depend on the intensity 28 and frequency of treatment which are all affected by rate of compliance. This leads to wastage of resources (both 105 human and financial) and may prolong treatment time and this can be a source of frustration to 102 104 105 healthcare practitioners. Further, prolonged treatment time will result in economic burden on the part of caregivers as 104 105 treatment becomes costly given that non-compliance also leads to diminished clinical 101 102 104 outcome/efficacy. In a qualitative study to explore non-compliance with home exercises in paediatric physiotherapy, lack of time was cited as the major stumbling block. On the same wavelength, a survey of chiropractors perceived barriers to compliance revealed that 91. Additionally, lack of time makes it hard to integrate home exercise programs into the patients busy 102 112 111 schedule and a busy schedule and inherent forgetting leads to non-compliance. In a qualitative study exploring compliance with exercise in knee pain patients, those experiencing severe pain and or loss of mobility were the 109 ones who were more likely to be compliant. Additionally, beliefs towards causes of a condition affect subsequent compliance with exercise. In essence, for patients who suffered from arthritis of the knee, those who believed it to be cause by immutable factors such as age, obesity had a more 112 resigned attitude towards arthritis and were less likely to be compliant. This is very important to note especially in the context of low income nations where there is no adapted public transportation for people with 29 115 disabilities.
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Mortality and morbidity Increased risk of death in infancy with high spinal lesions gastritis colitis cheap biaxin 250mg fast delivery, open lesions and multiple malformations gastritis diet ìòñ order biaxin american express. Quality of life affected by sequelae and functional limitations rather than level of lesion per se gastritis symptoms pain in back discount 250mg biaxin with visa. Tonsillar descent in young children may resolve spontaneously with posterior fossa growth xifaxan gastritis order biaxin 500mg without prescription. The association with spina bida is directly causative: the higher the spinal lesion the more severe the Chiari malformation acute gastritis symptoms nhs order biaxin 500mg on line. Long-term gastritis diet ðóíåòêè generic biaxin 250 mg amex, regular (at least annual) ophthalmological review (particularly of visual elds) is required to detect early signs gastritis severe pain order biaxin 500mg mastercard. In contrast to high pressure headache symptoms are relieved by lying down and worsened by sitting up gastritis diet chocolate discount biaxin 250mg otc. Bacterial infection is usually associated with a polymorpho- nuclear response in the subarachnoid space; viral, tuberculous and fungal infection causes a lymphocytic response. Meningitis is divided into acute (develops over hours to days) and chronic (days to weeks) forms. This generates an immune response and an inammatory cascade killing the bacteria, but also causing brain injury (Table 4. If meningococcal infection is suspected, or the child is extremely ill and meningitis is suspected, start treatment prior to investigation. Contacts For HiB and meningococcus, with rifampicin at 10 mg/kg for 4 or 2 days, respectively. Fluid restriction may further compromise cerebral circulation, so before restricting uids check plasma and urinary sodium and osmolality, and urine output. In the majority of cases, this primary infection passes unnoticed, with only the development of a positive tuberculin skin test to indicate that infection has taken place. Diagnosis is often difcult to conrm initially, and needs to be based on clinical suspicion. Acetazolamide or ventriculoperitoneal shunting may be used for hydrocephalus (usually communicating. Clinical features include headache, fever and neck stiffness fol- lowing a prodromal u-like illness. Causative agents Enteroviruses (responsible for 85% of cases) Include echovirus, Coxsackie, poliovirus. Mumps Parotitis, orchitis, pancreatitis with elevated amylase and lipase (extraneural manifestations occur in 50% cases. Features are of developmental stagnation, and later neurological and general cognitive regression with pyramidal signs, hypokinesis and evolving dysphagia and feeding difculties. In older children, deteriorating school performance, social withdrawal, and emotional lability are seen. May have insidious onset with abnormal behaviour/memory problems that can be mistaken for psy- chiatric illness. The former is usually found in the immunocompetent and typically leads to arterial stroke (see b p. Small vessel encephalitis usually occurs in the immunosuppressed: zoster infection occurred weeks to months earlier, followed by chronic progressive encephalitis. If relapse occurs, re-treat and consider prophylaxis with oral aciclovir or valaciclovir for 90 days. Non-viral causes of infectious encephalitis Viral causes are found in approximately 50 %cases of encephalitis. Increasingly suspected that some presumed viral encephalitides may be autoimmune (see b p. Consider the following if no viral cause is found especially if there is an appropriate travel history or if the child is immunocompromised. Other causes of pyogenic meningitis/abscess: especially if septicaemia and micro-abscesses are possible. Anterior horn cell infection Polio Polio virus is an enterovirus causing biphasic febrile illness with initial prodrome then further fever with acute-onset asymmetrical progressive accid paralysis of one or more limbs. Enterovirus 71 Causes outbreaks of hand, foot and mouth disease in the Asia-Pacic region. May develop polio-like neu- rological manifestations with or without meningitis or encephalitis. Anaerobes such as bacteroides, Streptococcus milleri and Fusobacterium are also commonly found. Direct extension can occur from the ears or sinuses, or abscesses can develop following trauma or meningitis. Antibiotic treatment alone is often insufcient, and surgical drainage needs to be considered. Aspiration and/or excision relieve pressure and enable a microbiological diagnosis. Radiological resolution is frequently slow, with a ring lesion persisting for weeks to months. Other possible treatments include quinidine, artemisan derivatives, or sulphadoxine/pyrimethamine. Complications Mortality is high at around 20%, but in those that survive, the majority (780%) have a normal outcome unless venous infarction occurs. A single lesion may pose diagnostic dilemma as it is difcult radiologically to exclude tuberculoma. Surgical resection is occasionally required after drug treatment for large lesions. Hyperdensities on T2-weighted images are seen in the periventricular frontal, temporal and occipital white matter. Approximately 50% of children will have increased signals on T2-weighted images in the basal ganglia and thalamus. Generalized cerebral atrophy and ventricular dilatation occur with disease progression. They are reports from open trials that combinations of antiviral drugs (ribavirin, inosiplex and interferon A) may be worth considering. The incidence may have now peaked although this is not certain: concern remains that all cases to date have had a minority polymorphism in prion protein which may have a short incubation period. Active surveillance is being main- tained in case a second wave develops in the majority population with longer incubation period. Clinical features Early symptoms are psychiatric: withdrawal, depression and anxiety. Then there is a decline in school performance and painful paraesthesias in the limbs. After approximately 6 mths, ataxia and involuntary movements (dystonic, choreiform, and myoclonic) develop. There is progressive neu- rological decline with dysphasia, dementia, dysphoria, rigidity, hyperreexia, and primitive reexes. The types of organisms that pose a risk depend on the cause and precise nature of the immunodeciency: Decient B cell function Meningitis caused by encapsulated bacterial pathogens. The question is often whether this is this infection or a complication of treatment Differential diagnosis: collagen vascular diseases, sarcoidosis, lymphoma, complement factor 1 deciency, meningeal carcinomatosis, structural causes. Cytomegalovirus infection the most common and potentially serious congenital infection. Primary maternal infection in the rst or second trimester (which is often asymp- tomatic) will result in foetal infection in 60% of pregnancies. Infection is usually persistent (50% still have virus in the urine aged 5 years) and may cause progressive damage, particularly sensorineural hearing loss and retinitis. Infection in later postnatal life is commonly asymptomatic and seropositivity is very likely to be coincidental. Risk factors include contact with cat litter or faeces, and eating undercooked meat. May have these features without any neurological syndrome at birth, but develop neurological abnormalities later. Outcome Even those with asymptomatic infection may have problems identied later including learning difculties, hearing impairment, and retinitis. For those with symptomatic infection, the neurological outcome depends on the severity and location of brain damage. Foetal infection is acquired transplacentally after primary (usually asymptomatic) infection in the mother. The frequency and severity of infection are greater the earlier in gestation it occurs. Ocular abnormalities include salt and pepper retin- opathy, cataracts (pearly and central) and microphthalmia. Outcome 90% symptomatic infants will have sequelae including motor decits, microcephaly, cognitive impairment, behavioural problems, and hearing loss. Severe cases have multi-organ involvement: predilec- tion for reticulo-endothelial system (anaemic, jaundice, bleeding. Specic features include vesicular mucocutaneous lesions (often over the site of viral entry), conjunctivitis, and keratitis. If infection is localized (without visceral involvement), symptom onset is later (2nd or 3rd week of life. Systemic features Features not usually present until the infant is at least 2 weeks old. If the mother has been treated in pregnancy, treat- ment of the infant may not be necessary. Genetic understanding of conditions causing this picture has improved considerably in recent years. Other brain abnormalities reported including hypoplasia of the corpus callosum and cerebellum, small brain stem, and abnormal pituitary. They can also develop a large vessel cerebral arteriopathy and are at risk of cerebral haemorrhage. Management is currently symptomatic with no benet demonstrated as yet for immunomodulatory treatment. If positive consider the following investigations depending on the neurological syndrome. The key is to remember to ask the question, if only to exclude it: if you do not think of it the diagnosis will be missed! A particular comment on late presentations of urea-cycle disorders Presentations may be acute or chronic, and vary with age. Acute porphyrias Hereditary porphyrias are a heterogeneous group of eight disorders of haeme biosynthesis. Samples are likely to be false-negative between attacks and repeated testing even during attacks may be necessary if suspicion is high. As with many genetic conditions the observed clinical phenotype may be caused by different mutations in either the nuclear or mitochondrial genomes and, conversely, a single genotype can give rise to several distinct phenotypes. Mitochondrial genetics the sometimes marked genotypic/phenotypic variation has several causes. Clinical presentations Mitochondrial disease can present at all ages, but are increasingly recog- nized in childhood. Multiple, apparently unrelated organs can be affected typically including combinations among: muscle, heart, eyes, brain (including hearing, seizures, extrapyramidal syndromes), liver, blood, and pancreas. Some combinations have been dened as syndromes, although even these can be incomplete or overlap. Typically, these are slowly progressive: the main differential in practice is myasthenia. Symmetric high T2 signal of the basal ganglia and brainstem is effectively the radiological counterpart of Leigh syndrome (histori- cally dened pathologically) and is particularly suggestive of mitochon- drial disease (although there are alternative causes. Areas of infarction associated with mitochondrial stroke-like episodes tend to occur in the parieto-occipital regions and often do not conform to a single vascular territory. A combination of deafness and diabetes (or family history of such combinations) is very suggestive. Cardiac involvement Unexplained hypertrophic or dilated cardiomyopathy may require trans- plantation, but this option should be carefully considered in the context of multisystem disease. Pancreatic disease Exocrine pancreas dysfunction (resulting in fat malabsorption and steatorrhoea) or endocrine dysfunction causing diabetes. Histochemistry Characteristically ragged-red bres: irregular reddish patches around the circumference of bres visible on Gomori trichrome stain, representing accumulations or proliferations of abnormal mitochondria. Leigh syndrome Involvement of the brainstem and basal ganglia structures: originally dened pathologically but now essentially a radiological diagnosis. Its importance lies in identifying pre-symptomatic rst-degree relatives who can benet from immunization and prophylactic antibiotics to reduce risk of acute deterioration. A clinical picture of onset is seen in the toddler age group of refractory status epilepticus (often epilepsia partialis continua) sometimes progressing after weeks or months to include deranged liver function. This progresses over several weeks typically sequentially (one eye then the other) associated with swelling of the optic nerve head in the acute phase.
See Date of Last Contact Flag for an illustration of the relationships among these items gastritis diet oatmeal cookies biaxin 500mg on line. This event occurred gastritis diet 60 purchase biaxin discount, but the date is unknown (that is gastritis diet key order 250 mg biaxin otc, the date of last contact is unknown gastritis diet ýëüäîðàäî order biaxin 250mg on-line. Vital Status is not changed gastritis diet lentils discount biaxin line, but neither is the Date of Last Contact or Death changed gastritis diet ýëüäîðàäî cheapest biaxin. Code Label 0 Dead 1 Alive Examples Code Reason 0 Death clearance information obtained from a state central registry confirms the death of the patient within the past year gastritis reddit order biaxin 500 mg with visa. Rationale this data item is useful when the same patient is recorded in multiple registries chronic gastritis forum 250mg biaxin amex. Rationale this data item is used by registries to identify the most recent follow-up source. Coding Instructions Code Label Definition 0 Reported Hospitalization at another institution/hospital or first admission to the hospitalization reporting facility. Rationale this data item is used by registries to identify the method planned for the next follow-up. Rationale this item can be used for quality control and management in multistaffed registries. This enables the CoC to manage the receipt of historical data and to appropriately attribute these data. Rationale It is essential for hospital registries to have the ability to distinguish cases originally accessioned by each registry of the merged unit. Rationale this item was created to measure abstracting timeliness of information that should be available when the facilitys main involvement in the patients first course care is completed, based on Class of Case. This data item is required for CoC-accredited facilities with submission starting 01/01/2018. This data item will facilitate identification of the purpose of the data submission at the receiving end. It is important to verify that the non-microscopically-confirmed case is indeed a separate primary from any others that may have been reported. This edit forces review of multiple primary cancers when one of the primaries is coded to a site other than ill-defined or unknown and is not microscopically confirmed or confirmed by a positive lab test/marker study. Also check for other data items on the remaining cases that may need to be changed as a result of the corrections, such as stage and treatment. The CoC version of the edit will accept Override CoC- Site/Type or Override Site/Type as equivalent. They force review of multiple primary cancers when one of the primaries is coded to a site-morphology combination that could indicate a metastatic site rather than a primary site. Pediatric stage groups should not be recorded in the Clinical Stage Group or Pathological Stage Group items. If the edit generates an error or warning message, check that the primary site and histologic type are coded correctly and that the age, date of birth, and date of diagnosis are correct. If the patient had a surgical procedure, most likely there was a microscopic examination of the cancer. Review of these cases requires investigating whether the combination is biologically implausible or there are cancer registry coding conventions that would dictate different codes for the diagnosis (See Cancer Identification in Section I. Review of these rare combinations often results in changes to the primary site and/or morphology, rather than a decision that the combination is correct. The distinction between in situ and invasive is very important to a registry, since prognosis is so different. Very rarely, a physician will designate a case noninvasive or in situ without microscopic evidence. If an edit of the type, Diagnostic Confirmation, Behavior Code, gives an error message or warning, check that Behavior Code [523] and Diagnostic Confirmation [490] have been coded correctly. Check carefully for any cytologic or histologic evidence that may have been missed in coding. This edit forces review of these rare cases to verify that they are indeed in situ or malignant. The registrar may need to consult a pathologist or medical advisor in problem cases. Note: the Morphology-Type/Behavior edits are complex and perform several additional types of checks. Remember that positive hematologic findings and bone marrow specimens are included as histologic confirmation (code 1 in Diagnostic Confirmation) for leukemia. Conversely, if inadequate information is available to determine a specific primary site, it is unlikely that information about a cancer being in situ is reliable. A primary site within an organ system can sometimes be identified based on the diagnostic procedure or treatment given or on the histologic type. If a more specific site cannot be determined, it is usually preferable to code a behavior code of 3. In the exceedingly rare situation in which it is certain that the behavior is in situ and no more specific-site code is applicable, set Override Site/Behavior to 1. If diagnosis year is greater than 1987 and Histology equals 9140, 9700, 9701, 9590-9980, then no further editing is performed. The intent of this edit is to force a review of in situ cases for which Laterality is coded 4 (bilateral) or 9 (unknown laterality) as to origin. For cases diagnosed in 2010 or later, Laterality must be coded 5 for midline tumors. Rationale Knowledge of the coding system that describes the meaning of the codes currently stored for each case is necessary for interpretation of the coded data. It is also necessary for correct conversion of the record to a different coding system or to a different registry software system. Examples Code Reason 00 A case accessioned in 1980 was coded according to codes developed locally by the hospital before it became involved in the Commission on Cancer Approvals Program and no conversion of the record has occurred since its accession into the registry. In 1989, the registry records were converted to conform to the codes defined in the 1989 Data Acquisition Manual. The conversion of this record to a more recent coding system is not possible due the uncertainty of its original coding system. Rationale the coding system used when a case is originally coded limits the possible categories that could have been applied to code the case. Because code categories may change over time as new coding systems are developed, this item is used to assist interpretation when cases that may have been coded originally according to multiple coding systems are analyzed. Ordinarily, it will not be necessary to use code 99 for cases accessioned in 2003 or later. The registry data were subsequently converted in 1996, 1998, and 2003 with the publication of each manual. To accurately group and analyze data, it is necessary to record the system used to record the race codes. Identifying both the original and current coding systems used to code race promotes accurate data grouping and analysis. Converted codes have a slightly different distribution and meaning than codes entered directly. Cancer registries record case histories over many years, so not all cases will originally be assigned according to the same code version. Rationale this information is used for some data analysis and for further item conversions. New versions of the codes used for recording histology and behavior reflect advances in medical and pathologic knowledge, and converted codes have a slightly different distribution and meaning than codes entered directly. The allowable values listed in the header for Sex [220] were corrected to 1-6, 9 to reflect the addition of codes 5 and 6 in 2015. Other organs may include, but are not limited to , oophorectomy, partial proctectomy, rectal mucosectomy, or pelvic exenteration. The surgical code for the contralateral breast is coded to the procedure performed on that site. Reconstruction that is planned as part of first course treatment is coded 43-49 or 75, whether it is done at the time of mastectomy or later. The specimen may or may not include a portion of the pectoralis major muscle If contralateral breast reveals a second primary, it is abstracted separately. A debulking is usually followed by another treatment modality such as chemotherapy. Procedures may include, but are not limited to , cystoprostatectomy, radical cystectomy, and prostatectomy. If immunotherapy is followed by surgery of the type coded 20-80 code that surgery instead and code the immunotherapy only as immunotherapy. When a procedure is described as a pelvic exenteration for males, but the prostate is not removed, the surgery should be coded as a cystectomy (code 60-64. Other brain tumors, such as ependymomas, medulloblastomas, and ju- - Lymphomas venile pilocytic astrocytomas, mostly occur during childhood and are relatively - Medulloblastomas rare in adults. Most primary malignant brain tumors, such as gliomas and lym- - Outcome phomas, tend to be located in the supratentorial compartment. The prognostic factors and therapeutic management of patients with these Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel tumors are controversial because of their rarity, their heterogeneity, and the lack To whom correspondence should be addressed: of sufficient data in the literature. In this review, we characterize independent cohorts of patients Available online: Table 1 genetically, and clinically distinct groups of summarizes clinical, histopathologic, and posterior fossa ependymomas. Moreover, group A controversial because of their rarity, their Ependymomas arise from ependymal cells included other biomarkers known to be heterogeneity, and the lack of sufcient and mostly occur in the posterior fossa. As a result, the optimal treatment Posterior fossa ependymomas comprise repeat-containing 5, and S100 calcium- 1,4 binding protein A6. Attempts have been made to the histologic similarity of ependymomas, the prognostic factors and the pattern of identify prognostic factors for patients, they are very heterogeneous tumors. The authors reported that received postoperative radiation therapy signicant prognostic factors can probably 75. Overall, the existing literature fossa ependymomas in adults continues to be cerebrospinal uid diversion, were identi- supports a role for a maximal extent of controversial, and there are essentially no ed as being associated with worse func- surgery and the preoperative performance standard clinical guidelines for treatment. Radiation therapy for ependymomas are warranted to assess the actual impact in the posterior fossa. One patient who received In contrast to pediatric medulloblastomas, tion/amplication and an elevated genomic concomitant chemotherapy was also which tend to be located in the vermis, tu- instability with frequent chromosome 1p treated with temozolomide. Performance mors in adults tend to involve the cerebellar gains, 10q and 5q loss, and the presence of status before and after surgery, as 20 isochromosome 17. Another difference from measured by the Karnofsky performance pediatric tumors is the greater prevalence largest subgroup, accounting for 35% of all scale, was strongly associated with of late recurrence. These results suggest that adults includes maximal safe resection followed by tumor recurrence. Patients are usually either different cytogenetic, mutational, and gene risk patients. Moreover, there is no observed expectantly or offered upfront expression signatures; demographics; consensus regarding the specic regimen to adjuvant treatment. Specically, associated with survival in this patient clear protocol at the present time. Although an intratumoral cyst results from tumor population and compare them factors no randomized controlled studies have necrosis, whereas a peritumoral cyst is the associated with survival in patients with assessed the role of reoperation, retro- result of surrounding interstitial pressure, supratentorial glioblastomas. It seemed that spective clinical series suggest that, when increased tumor vascular permeability, and cerebellar glioblastomas tended to occur in feasible, patients should undergo repeat tumor surrounding edema. Tumor removal leads tients who presented with a mixture of true and endolymphatic sac tumors. The rest of to resolution of the peritumoral cysts, and cerebellar gliomas with tumors with brain- the hemangioblastomas occur sporadically. Previous important to carefully inspect the cyst wall patients with a diagnosis of supratentorial clinical studies tended to mix sporadic intraoperatively to detect small tumor foci. All 18 patients had multiple, evolve rapidly, and occur in hyperintense lesions on uid attenuated younger patients (mean age of 29 years. Of18patients,12had terious impact on the quality of life of the few clinical series with limited numbers of high-grade gliomas, and 6 had low-grade patients. Biopsies were not performed in 25,26 most of the posterior fossa tumors, and it the radiologic appearance of a heman- have been reported. Overall, it was un- associated cysts, with associated peritu- glioblastomas are rare and constitute only clear whether this progression represented moral cysts, and with both peritumoral and 0. The mechanism Epidemiology and End Results national rior fossa involvement was associated with a of peritumoral cyst formation is different database during the years 1973e2009. Rapid recurrence and malig- nant transformation of pilocytic astrocytoma in Intracranial Dermoid Cysts obtained. It was pedestrian research but good training in careful measurement, repeat variability, dening the normal, simple statistical analysis, and practical aspects of survey methods. From travels about the world with Paul Dudley White, the international dean of cardiology, he would return to Minnesota with bountiful news and hypotheses about cultural differences in the frequency of heart attacks. The Holy Grail lay, he suspected, in the diet and mode of life of populations living varieties of traditional lifestyles. In the summer of 1949 in eastern Cuba I had discovered the severe limitations of medicine to cope with mass diseases due mainly to poverty and ignorance. These were matters for public health and the political economy, quite beyond the meagre efforts of medical missionaries. From these exposures I was primed, when the opportunity arose, for a career in public health and for a population view of epidemic cardiovascular diseases. Ancel Keys 1956 invitation to become a research associate in The Lab and project officer for the cross-cultural Seven Countries Study of cardiovascular diseases, offered an international career exploring a major phenomenon of public health and involving my early interests and experience. The same day as Keys invitation, I received the offer of a junior faculty position in the medical school. I soon learned from its annoyed chief of medicine that my signing on with Ancel Keys and those weird people doing those crazy things under Gate 27 of the football stadium, would almost certainly exclude me from the academic elite of internal medicine! Interesting and important things, including the birth of cardiovascular disease epidemiology, were under way at Minnesota and abroad. A few pioneers in the trenches, mainly experts in cardiovascular fields and most without epidemiological training, integrated evidence from these several sources. Coincident with these activities were new directions in research and training at the London School of Hygiene and Tropical Medicine and soon thereafter in numerous centres worldwide (Morris 1957. A few leaders turned their curiosity about the causes of the epidemic to the community and culture from which the many cases derived. Hypertension was known to have a direct relation to heart failure and to stroke but its connection with heart attack was not clear, and at any rate there was little to be done about it. Vascular diseases generally were relegated to an inevitable consequence of aging. The importance of cholesterol, long known as a main com- ponent of arterial plaque and a cause of experimental dietary atherosclerosis, was for many years pooh-poohed, along with habitual diet, as a simplistic causal view of something as complex as atherosclerosis (Jeremy Swan, personal communication, early 1970s. Smoking and obesity were merely distasteful; physical activity was dangerous and unfashionable; stress and heredity were fundamental but inescapable. Reduce your weight, was about as far as preventive practice went in the late 1940s. In the early twentieth century, they hypothesized that a rich diet was responsible for accelerated aging and atherosclerosis. In those ourishing days for experimental pathology, they fed human diets to rabbits, producing fatty arterial lesions resembling those of human disease. Anitschkow determined that dietary lipids and cholesterol, rather than protein as Ignatowski postulated, were the arterial pathogen. His classic review of experimental atherosclerosis, in Cowdrys popular text of the 1930s, anticipated virtually every issue about atherogenesis explored since that time, including regression of atheroma (Anitschkow 1933. Anitschkows findings and syntheses were widely disseminated, stimulating much clinical- pathological study and causal ideation (McGill 1968. Diagnosis At the turn of the twentieth century, Wilhelm Einthoven of Leiden developed the string galvanometer electrocardiograph, which vastly facilitated cardiological diagnosis, particularly after its clinical application by the British investigator, Thomas Lewis (Einthoven 1903. Some years later, Herricks description of myocardial infarction with survival is generally given priority in Western medicine for establishing the syndrome of clinical and electrocardiographic manifestations (Herrick 1912; White 1948. The electrocardiogram became the major diagnostic tool in early clinical and epidemiological studies of coronary heart disease. Stroke, on the other hand, was properly diagnosed much earlier, though it was only with devel- opment of brain imaging in the 1970s that its origins were successfully differentiated, during life, as thrombotic, embolic, or haemorrhagic.
