If the committee fnds cannot be resolved to the satisfaction of the against a post-graduate trainee buy finast 5mg without prescription hair loss during pregnancy, the fnd- Associate Dean for Student Affairs discount finast 5 mg mastercard hair loss in men 90s fashion, or where ings will be communicated to the appropri- the gravity of the acts with which the student ate Department Chair and Program Direc- is charged appears to warrant further atten- tor and sanctions will be determined and tion discount finast 5 mg fast delivery hair loss in men 39, the Dean of the Medical Faculty will enforced according to the policy on Pro- appoint an ad hoc committee of the Adviso- bation, Suspension, and Termination of ry Board of the Medical Faculty to hear the Post-Doctoral Fellows published elsewhere charge of misconduct. Suspension for a specifed time or until mittee and may vote when the ad hoc com- explicit* conditions are met. Unconditional Expulsion given written notice of the charges and of the date and time of the Committee hearing. Prior *Explicit conditions are to be unambiguous to the hearing an accused student shall be and as objective as the conditions allow. An accused stu- sion to the Dean of the School of Medicine, dent may request an opportunity to consult or, in the absence of the Dean, appeal may with the Dean, Vice Dean, or an Associate be made to the Vice Dean or an Associate Dean prior to a hearing. A student may be accompanied to the calendar days of the date of the committee hearing by a faculty member or student advi- decision. A student may attend classes pending or the accusing party at the hearing by attor- the proceedings before the ad hoc commit- neys will not be permitted. In the course of the hearing, a student will Vice Dean, or Associate Dean to be a danger be given the opportunity to present evidence to himself or others. A student must seek the and witnesses in his behalf, to question all permission of the Dean, Vice Dean, or Asso- witnesses, and to make statements to the ciate Dean in order to continue the education- Committee. Members of the ad hoc committee may ask questions of the student charged and of wit- nesses appearing before the Committee. A hearing before the ad hoc committee will be closed and persons other than Deans Preclinical Curriculum appearing as witnesses will be asked to Among the goals of the Scientifc Founda- absent themselves before and after their tes- tions of Medicine and the Genes to Society timony. Parents of the accused student will be courses are to develop a sense of profes- permitted to accompany a student throughout sionalism, to promote collegiality, to engage the hearing, and, if they should wish to do so, students in teaching one another, and to give to make a statement. A hearing shall be recorded but the delib- different backgrounds and expertise are rep- erations of the ad hoc committee shall not resented. Following the hearing, the student to be actively engaged, therefore accused student shall be permitted to listen attendance is mandatory at all group learn- to the recording upon request, but all copies ing and teamwork activities including activi- of the recording shall remain in the School’s ties in the Simulation Center and workshops. All parties, witnesses, and representa- that involve patients and/or guests, such as tives shall be excused at the conclusion of clinical correlations. Videofles of large group the hearing and the ad hoc committee shall lectures where attendance is not required deliberate privately. The Committee shall are available online via course management make fndings as to the truth or falsity of the software. Unexcused attendance below 80% the Committee decide that the student’s will affect the student’s performance in the behavior warrants discipline, will include, but course and will be considered a breach of will not necessarily be limited to the following: the standards of professionalism expected by a. Probation for a specifed time period or Group Discussions), attendance at 80% of until explicit* conditions are met. Students Excused absences may be granted in should make every effort to leave as late as cases of illness, religious observance, fam- possible and return as early as possible when ily emergency, presentations at scientifc interviewing to minimize time lost from a core conferences, or required legal activity (e. On 6-9 week clerkships, students will be whenever feasible) with the section director, allowed to miss 3 full days of responsibili- course director, and/or Associate Dean for ties as excused absences for interviews. Students must inform course directors Attendance Policy of any such absences in advance of the The School of Medicine recognizes the pri- beginning of the clerkship when possible. Atten- be considered unexcused and will impact dance rules are governed by the School of on the student’s fnal grade. Students should expect to The holidays which occur during the Clerk- attend required basic clerkship educational ship time generally fall on a Monday or Fri- activities after they have completed the exam. If this occurs, scheduled activities activities may be scheduled on those week- for these other courses take priority over all end days at the discretion of the Clerkship scheduled Clerkship activities. Elective Coursework public or civic events are not considered holi- Under no circumstances will elective course- days for Core Clerkship students. Students will not be excused from Excused & Unexcused Absences required Core Clerkship duties to attend a. This includes elective ensure that students obtain suffcient experi- experiences requiring complex or expensive ence in each of the basic disciplines to meet travel arrangements, such as those con- the objectives of the Hopkins curriculum. Illness or Injury (Personal or Family) Holidays) Illnesses or injuries are handled on a case by Students must notify the Clerkship Director case basis by Clerkship Directors. In almost as early as possible before the start of the all cases, such events cannot be predicted in clerkship regarding any scheduled absence advance. When either occurs, the student’s other than those described above, and should frst responsibility is to their own personal expect that they will need to make up missed safety and the safety and well-being of those time. Once the situation has stabi- absence for religious holidays, academic lized suffciently and it is safe to do so, a stu- events (e. As necessary, remediation plans will be tial impact on the educational experience, the made on a case-by-case basis by the Clerk- general rule is “a day for a day” (i. Students who of the educational experience is missed for must miss a class or an examination because any reason, it is at the Clerkship Director’s of a religious holiday must inform the instruc- discretion to require remediation, reduce the tor as early as possible in order to be excused student’s grade, or remove the student from from class or to make up any work that is the Clerkship that cycle. Weather and Other Related Emergencies Clerkship slot, potentially delaying promotion Within the Baltimore Area or graduation in some circumstances. Weather-related policies are stipulated by Students who fail to attend required activi- the Johns Hopkins University. Clerkship Orientation) without ship students are not considered “Required advance notice and are unable to offer a rea- Attendance Employees” and are excused sonable or appropriate justifcation (as judged from attendance at normally-required Clerk- by the Clerkship Director) may be subject ship activities if affected by circumstances to grade reductions, failure, or disciplinary (e. As necessary, remediation plans Any student who feels unfairly treated with will be made on a case-by-case basis by the regard to attendance or duty hours policy Clerkship Director. If a mutually agreeable deci- Outside the Baltimore Area sion is not reached, the student should con- Students who travel during (e. Once the student’s safety is assured, they In recognition of the primacy of the educa- should immediately notify people related to tional goals for students enrolled the full- the Clerkship, as appropriate (e. Stu- provide guidance to students, faculty, and dents will generally be required to remediate administrators: any time or activities upon safe return or at a 1. Students must be in good academic stand- tant Deans of Student Affairs to obtain approv- ing in order to be eligible for employment by al for the event. Documentation of this stand- ing will be coordinated by the Offce of Student Financial Aid Affairs. If there is evidence that the student’s academic performance is placing the student Satisfactory Academic at-risk for failing, in addition to the usual sup- ports offered in these situations, the student’s Progress Review employment status will be reviewed by the Federal law and regulations require that all Offce of Student Affairs in collaboration with students receiving federal fnancial assis- the student. This could result in termination of tance must maintain satisfactory academic University employment. The policy applies to all students who Offce of Student Affairs describing the pro- receive federal fnancial aid assistance. This form also requires In determining student’s academic prog- information from the proposed supervisor of ress, the Financial Aid Offce will follow the the employment and an acknowledgement on School of Medicine’s Student Promotion their part of awareness of this policy. Committee academic review policy which is established for all students and meets the 4. Student academic standing and satisfac- However, only six weeks of paid elective credit tory academic progress will be reviewed can count toward the cumulative elective cred- annually by the Financial Aid Offce to deter- it required for graduation. Evaluations will be the Offce of Student Affairs and could result made on both a qualitative and quantitative in disciplinary action or referral to the appropri- basis. Alcohol Policy for Qualitative Review The Financial Aid Offce will follow the rec- Medical Students ommendations of the Committee on Student Promotions for the qualitative review of aca- Intoxication in the workplace is considered demic progress status of the student.
Ann Intern Med 1989; A detailed analysis of the characteristic pathologic changes 110:714–718 associated with drug-induced adverse pulmonary effects that 84 purchase finast 5 mg amex hair loss 4 months after childbirth. Ann Intern Med 1997; 127:356– 364 Annotated Bibliography A multicenter buy finast online pills hair loss cure genetic, case-control study demonstrating the stron- gest clinical predictors for lung injury finast 5mg with mastercard hair loss in men vs women. Chest Chest Med 2004; 25:53–64 1991; 100:1391–1396 A succinct review of adverse pulmonary effects from new and A concise review of acute and chronic salicylate toxicity. In patients with tion in complication rates or increased mortality preexisting left bundle-branch block, the potential and use of resources, in comparison with patients for development of complete heart block exists. Atrial pressure waves can of complications, and capable of appropriately usually be recorded from the right atrium and the interpreting and utilizing the data obtained. In general, present, continued occlusion of the pulmonary trends in these measurements over time are more vessel (“overwedging”) is possible and requires useful clinically than single values. The pulmonary vascular system distal to tachycardia ( 120 to 130 beats/min) or pulmonary the catheter tip must be patent and provide a blood- hypertension (eg, chronic lung disease or hypox- ﬁlled connection with the left atrium. Balloon inﬂation converts zone interrupts ﬂow and allows transmission of pressure 2 to zone 1 conditions by stopping blood ﬂow and back from the pulmonary veins and, ultimately, the allowing collapse of the vessel distal to the balloon. Pressures and venous pressures exceed alveolar pressures within the left atrium are a reﬂection of the pressure and capillaries remain open providing the neces- within the left ventricle at end-diastole. Placement in non-zone 3 areas of the ventricle (pressure-volume relationship) and or conversion of zone 3 to other zones can occur transmural ventricular distending pressure (intra- with hypovolemia, change in patient position, or cavitary pressure less juxtacardiac pressure). Conditions That Alter Pressure and Volume the proximal port (right atrium) with detection of Relationships* a temperature change by a thermistor at the distal end of the catheter. Mitral valve regurgitation Thermodilution cardiac output generally has a good Pulmonary venous obstruction/vasoconstriction Intracardiac shunt (left to right) correlation with the Fick or dye dilution technique. Stroke volume is estimated from this may be present despite high pulmonary capillary velocity using a nomogram and measurement of pressures if marked resistance exists. Proper positioning is necessary (eg, pulmonary embolism and hypoxia) and phar- for accurate measurements, and requires training macologic alterations (eg, prostaglandin admin- and experience. Patients must be receiving controlled mechanical ventila- Determination of cardiac output by thermodilu- tion because an increase in minute ventilation tion involves the injection of an indicator through during the rebreathing period in spontaneously 350 Hemodynamic Monitoring and Shock (Zimmerman) breathing patients reduces the accuracy of the car- Although this measurement is often used to diac output estimation. Inaccurate measurements reﬂect changes in cardiac output, decreases in arte- also result with low minute ventilation, high shunt rial oxygen saturation (hypoxemic lung disease) fraction, and high cardiac output. A normal Svo2 in a stable patient Analysis of the arterial pressure waveform is usually indicates that tissue oxygen needs are used to compute stroke volume with or without being met. An exception to this rule is in sepsis and initial calibration of cardiac output by transpul- certain poisonings (eg, cyanide), in which tissue monary thermodilution or indicator dilution (eg, hypoxia may exist with normal or elevated Svo2. Studies of the reliability, validity, and clini- cal utility of the less invasive techniques report Clinical Indications for Hemodynamic variable results. The advantages, disadvantages, Monitoring and limitations of the various techniques suggest that a single method may not be applicable to all Myocardial Infarction and Heart Failure patients. The recognition of ischemic right ven- blood must be eliminated to allow for catheter dead tricular dysfunction has implications for treatment space before removal of blood for analysis. Inaccurate measurements also occur in the a steep y descent, and a right ventricular pressure presence of severe mitral regurgitation, left-to- tracing with a diastolic dip and plateau (square right cardiac shunts, and distal tip placement. The right atrial pressure may increase catheters and special central venous catheters that during inspiration (Kussmaul sign) or with the provide continuous measurement of Svo2 make use hepatojugular reﬂux maneuver. The differentiation regurgitation from other complications if echo- of the two types of pulmonary edema is important cardiography is not readily available. Tricuspid Regurgitation Acute Cardiac Tamponade Tricuspid regurgitation usually occurs in the Echocardiography is most commonly used to setting of pulmonary hypertension and right ven- diagnose pericardial effusion and its hemodynamic tricular dilatation. In severe tricuspid pattern of acute cardiac tamponade includes eleva- regurgitation, the right atrial pressure tracing may tion and equalization of right-sided and left-sided resemble the right ventricular pressure tracing. Additional clinical manifestations in shock are related to tis- Constrictive Pericarditis sue hypoperfusion, the compensatory responses initiated by shock, and the underlying etiology Constrictive pericarditis produces equalization of shock. However, early diastolic dip followed by a pressure plateau most patients with shock demonstrate features in the right and left ventricular pressure tracings. The different types of shock are characterized by hemodynamic patterns (Table 8) that assist Restrictive Cardiomyopathy The hemodynamic pattern in restrictive car- Table 7. Left-sided ﬁlling pressures tend to be Nonhemorrhagic (eg, external loss, interstitial ﬂuid higher than right-sided ﬁlling pressures in restric- redistribution) Distributive tive cardiomyopathy. Neurogenic (spinal shock) Anaphylaxis Thyroid storm Shock Cardiogenic Myopathic (eg, ischemia, cardiomyopathy) Mechanical (eg, valvular lesions, septal defects) Shock is a syndrome of impaired tissue oxy- Arrhythmias genation and perfusion that results from one of Obstructive the following mechanisms: an absolute or relative Massive pulmonary embolism decrease in oxygen delivery; ineffective tissue Tension pneumothorax Cardiac tamponade perfusion; or impaired utilization of delivered Constrictive pericarditis oxygen. Speciﬁc measurements may tions have the potential advantage of achieving not always be available, and clinical ﬁndings in a adequate volume resuscitation more quickly and speciﬁc patient may be variable due to the speciﬁc with smaller volumes. Some studies have sug- etiology of shock, the underlying cardiac function, gested that hetastarch solutions may be associated the duration of shock, and degree of resuscitation. Therapy with titrated The management of shock requires treatment boluses of ﬂuids (500 to 1,000 mL of crystalloid of the underlying etiology, and the restoration of and 300 to 500 mL of colloid) is recommended in adequate oxygen delivery and tissue perfusion. Some agents have individual patient should aim to optimize tissue combined effects (vasopressor and inotropic), perfusion without increasing myocardial oxygen and effects may vary with the dose. Hemoglobin concentration can be clinical trials that have established the superior- increased by blood transfusion and oxyhemoglo- ity of a single agent or combination of agents in bin saturation by the administration of supple- treating shock. Isotonic crys- talloid solutions or colloid solutions are equivalent Severe Sepsis and Septic Shock as long as an appropriate quantity is administered to achieve hemodynamic goals. Although some Consensus guidelines have been developed for studies have suggested that specific groups of the management of severe sepsis and septic shock. Grade of recommendation, 1B A systematic review of clinical studies to evaluate the validity • Control glucose concentration to a target value of of transesophageal Doppler ultrasonography. Crit Care Med 2008; Annotated Bibliography 36:296–327 A revision of the 2004 guidelines for severe sepsis and septic American Society of Anesthesiologists Task Force on shock based on new evidence and consensus. J Cardiothoracic Vasc Anesth 2004; 18:563– of the clinical and cost-effectiveness of pulmonary 572 artery catheters in patient management in intensive A study comparing three methods of determining cardiac care: a systematic review and a randomised controlled output in cardiopulmonary bypass patients. Use of the pulmo- A review of newer noninvasive monitoring techniques and nary artery catheter is not associated with worse outcome global indicators of perfusion. Accessed 358:111–124 April 2, 2008 Randomized, controlled trial of hydrocortisone therapy in the A self-paced educational program on basic principles of hemo- treatment of patients with septic shock showing no beneﬁt, dynamics, correct analysis of waveforms, and interpretation even in nonresponders to an adrenocorticotropic hormone of data developed by several critical care organizations. Speciﬁc risk factors • Improve antibiotic selection in the empiric therapy of have been identiﬁed, and there are regional differ- community-acquired pneumonia • Recognize the risk of avian inﬂuenza and community- ences in resistance rates. Organisms Associated with Community-Acquired age include typical organisms such as Streptococcus Pneumonia* pneumoniae, Haemophilus inﬂuenzae, and Moraxella Patient Type Etiology catarrhalis. The standard recom- Legionella sp (the “atypical” pathogens), either mendation for blood cultures has recently been alone or as part of a mixed infection; thus, all challenged. There are considerable data to suggest bacteremia was low, one blood culture if the risk that atypical coverage (either with macrolides or of bacteremia was moderate, and two blood cul- ﬂuoroquinolones) is associated with better clinical tures if the risk of bacteremia was high, 88% of outcomes, including reduced lengths of hospital bacteremias would be detected and 38% fewer stay and rates of mortality. In a prospective study, Arancibia and coccal urinary antigen should be measured, and coworkers16 identiﬁed that probable aspiration, aggressive efforts at establishing an etiologic diag- previous hospital admission, previous antimicro- nosis should be made, including the collection of bial treatment, and the presence of pulmonary bronchoscopic samples of lower respiratory secre- comorbidity were independent predictors of Gram- tions in selected patients, although the beneﬁt of negative pneumonia.
Later he changed his mind buy finast with mastercard hair loss zinc supplements, believing that it was probably more beneficial to try to use natural material to obstruct the replication of the virus order finast mastercard hair loss cure japanese. In late 1986 purchase 5 mg finast otc hair loss 19 year old male, Jabar Sultan had worked out his first protocol for in vitro tests on immune cells. The new head of the medicine department, where he was continuing to write up his PhD, knew little about immunology and put Sultan in touch with Dr Anthony Pinching for advice. It appears, however, that Dr Pinching did nothing to suggest ways in which Sultan might further his understanding of the subject. Nor did Dr Pinching offer any help on subsequent occasions when both Jabar Sultan and Dr Sharp went to see him. All the doctors at the meeting agreed to take part in carrying out pre-clinical experiments. In 1986, Jabar Sultan attended a conference in Florida to present his work on cancer. Some time after his first visit to Dr Pinching, Jabar Sultan contacted his previous supervisor, Dr Sharp, who was now working at the London Bridge Hospital. He asked if there was any possibility of continuing his work on cancer patients at one of the hospitals where Sharp was a consultant. Money which Dr Sharp had obtained for Brownings enabled Jabar Sultan to build an advanced laboratory at the Hospital. Jabar Sultan was insistent that any such trial would have to be given to patients while they were resident in the Hospital and not simply attending consulting rooms. Jabar Sultan and Dr Sharp disagreed about this, principally because residence in the Hospital normally entailed considerable cost. Sultan insisted this was important because the treatment was experimental and if anything should happen to a patient, a fully-equipped intensive care unit should be accessible. There was no argument over the next important matter, that any such trial treatments should be given to patients free. In 1989, both were still alive and their referring doctor was able to say that they had suffered no adverse results from the treatment. Contrary to what Campbell was to say, one London patient was relatively well, and happy with the treatment, the other was less well, but did not complain about the treatment. The American patient wrote to Barker: Since treatment in September 1988, administered under the supervision of Dr Sharp... My doctors here continue to monitor my blood profile bi-monthly, testing both T-cell counts and percentages... There was no reason why any of these first three patients should have harboured any ill-will towards Dr Sharp. Both had received their treatment free and neither of them appeared to have suffered any deleterious affects. In fact no one other than Duncan Campbell had ever suggested that adoptive immunotherapy had adverse reactions. When Sultan returned from Japan, Dr Sharp and he approached Dr Pinching once more and informed him of their observations. Jabar Sultan was to say that Pinching was if anything even more definite than before. The attention of the press was drawn to the abstract of the paper given by Sultan in Japan, 22 and in December the Daily Express carried an article about the tests. He even went so far as to ring the Express complaining that he was never consulted about the article and advised on the correction of errors. At best, the treatment was inhibiting the virus, and hopefully directing the immune-strengthened cells against the cells that harboured the virus. The Express article was picked up by a number of other papers, which published short articles. Both men wanted to continue with the work, but money would increasingly become a problem. At a meeting of the Committee and then later in writing, Dr Pinching reiterated his lack of faith in the work of Dr Sharp and Jabar Sultan and suggested that some of their proposed techniques might be hazardous. The lack of side effects is encouraging, as are, of course, the clinical responses. Because Sharp was aware that Brownings was in a dire financial state, he made a unilateral decision, which was later to rebound on Jabar Sultan and Philip Barker, to charge these patients for their treatment. Sharp was painted as a mercenary and callous man charging vulnerable people for a course of treatment which was ultimately to kill them. In the event, neither the patients nor their relatives actually paid any money to Brownings. In fact, Jabar Sultan reported that both cases had shown some short-term improvement after the treatment. The implication of this omission is very serious because Campbell gives the impression that their deaths were hastened by the treatment which Dr Sharp gave them. Dr Sharp and Jabar Sultan had looked for a doctor who, in order to offset costs, would agree to patients being treated in their hospital and be monitored by their own consultant. In early August 1988, Dr Sharp and Jabar Sultan had a meeting with Dr Gazzard in the Endoscopy Unit at the Westminster Hospital. Of the two new patients, one was very seriously ill; she had lost her memory and was unable to walk. According to Jabar Sultan, both patients were clinically improved following their treatment. The first patient began to remember more and started going out from the hospital for walks. Jabar Sultan remembers vividly the moment when she kissed her husband, and thanked him for donating his blood to her. While co-operating with Dr Sharp on the management of these two patients, Dr Brian Gazzard appears not to have expressed any dissatisfaction with either the form or the content of the treatment, to Dr Sharp or his locum at that time, Dr Keel. If any of these doctors had doubts about the ethics of Dr Sharp, during this period, they were bound to report him to the General Medical Council. If they suspected that Dr Sharp was, as Campbell suggests he was, killing patients, they should have reported the matter to the police. The decision to destroy the reputations of Dr Sharp, Jabar Sultan and Philip Barker, might of course have had nothing to do with the impropriety involved in setting out to charge two patients. Passionately in favour of bringing people together, he is steeped in cooperative ideas, a caring man. Almost immediately, perhaps in retrospect rashly, the Bergen Bank was willing to put £1. Philip Barker first talked to Dr Sharp in December 1988 and became the managing director of Brownings on January 23rd 1989. By that time, Brownings was already in trouble; Dr Sharp had spent almost all the £1. Philip Barker did not know this; at the one board meeting which he attended prior to starting work, he was surprised to find that finance was not discussed.
The intellectually disabled themselves may express grief in ways other than speech order generic finast pills hair loss cure news 2014, such as insomnia order generic finast online hair loss in men over 50, anorexia generic finast 5mg without a prescription hair loss cure news 2016, searching, externally-directed aggression, a decline in intellectual or other skills, incontinence, or indifference. The fact that intellectually disabled people are living longer means that more of them experience the death of loved ones. The relatives of suicides tend to be shocked, to search for an explanation, to find it difficult to share feelings, to feel guilty or stigmatised (often reinforced by the media and others: Harwood ea, 2002; de Groot ea, 2007), or to feel relief (if the relationship with the suicide was poor). There may be an increased mortality from suicide among the bereaved following suicide, although attribution of cause is difficult because, for example, there may be a shared tendency to affective disorder. The same difficulty applies to interpreting reports of a history of exposure to suicide attempts or threats by friends or relatives in the histories of suicide completers: shared cultural and genetic factors act as confounders. Therapists, who may themselves be severely distressed,(Hendin ea, 2004) should initiate early contact with the bereaved family. War produces many psychiatric casualties, including prolonged grief in young widows of combatants whose bodies have never been seen. The Sikhs do not mind if the body is touched by non-Sikhs but the 1559 other two groups do. Modern life in the West often means that people live far from families of origin so that coping with loss may be a lonely psychological task. Common losses, which elicit grief reactions, include close relatives, friends, sexual partners, social status, self-esteem, and even parts or functions of the body. His benevolent feelings can then be smothered by sadism without hurting the loved one because only himself is assaulting him. The memory is rejected, incorporated into the ego by identification, and finally it is brought before the superego for condemnation. Depression is more likely to follow loss if the relationship with the deceased was largely negative. According to Klein, we can handle loss better if we succeeded in childhood in relating to others, especially mother, as a whole person and were accepting of mixed feelings of love and anger. Winnicott saw the internalised image of a reliable ‘good enough’ mother from childhood as providing a lasting source of inner strength and confidence that helped us negotiate loss. Lieberman(1983) holds that morbid grief may develop and become life threatening if bereavement is concealed from a patient and not discussed soon after the loss. Blame may be aimed at the self or projected onto ambulance men, doctors, or elsewhere. Anorexia, preoccupation, declines in efficiency and constant going over the past are the order of the day. Normally, with the aid of defence mechanisms, recovery takes place over some months. Factors associated with maladaptive grief in families include poor or unsupportive communication, disengagement and stifling of emotional expression, excessive guilt or anger, blaming or fighting with other members, inability to resolve normal daily family conflicts, inflexible roles, and persisting dependence on the lost person. In other words, anything that avoids, distorts, or prolongs grief augers badly for the future. Of particular interest is the case of a woman who lactated as part of an anniversary reaction to the delivery of her stillborn child. The defences employed include: searching by the bereaved; denial of the loss; talking about the loss ad infinitum; intellectualisation (talks without facing the associated feelings); identification with the deceased (dressing or talking like him, identical symptoms to those suffered by the deceased, etc. C Murray Parkes studied bereaved psychiatric patients and devised his famous division of bereavement reactions into grief and modified grief and non-specific reactions. Grief and modified grief: typical or usual grief (see above) follows fairly predictable course over a period of months, culminating in a return of interest in the affairs of the world. Chronic grief is a magnified reaction spread over a long period of time, and the person may have guilt, self-blame, identification symptoms and/or aggressive or delinquent behavior. In the very young or very old, inhibited grief is manifested by symbolic expression. In a 13 month follow up almost one in ten subjects showed chronic grief but none had delayed or absent grief. The intellectually disabled respond to loss, often for the only person who understands them, with behavior or neurotic problems. They may be kept back from the funeral or placed in an institution with unfamiliar surroundings, often facing strangers for the first time, when their carers die. Young and Papadatou(2000) state that children should be encouraged (but not pressured) to attend funerals, be supported by trusted elders, and be given an opportunity to see and touch the deceased. When a young child is cared for by strangers in a foreign environment he often shows a classical sequence of responses: protest, despair, and then detachment. When the child returns home he shows clinging behavior because of separation anxiety. Emotionally neglected children may show none of the normal fretting and so on when placed in hospital. John Bowlby and others have undertaken detailed studies of the development of affectional bonds and the consequences of their disruption at the Tavistock Clinic. Mothers were not to find their children unavailable outside hospital visiting hours. The separation was most traumatic when the child was in his second or third years. From this work developed a form of psychotherapy for anxiety, depression or emotional detachment. Later on we know that if a boyfriend talks to another girl he has not necessarily decided to be unfaithful. Failure to incorporate these emotion-laden lessons is at the root of much adult morbid jealousy and separation anxiety. Parental loss before the age of 17 years has been said to increase the chances of depression developing in later life. What may be more important is the reason for the loss - it may be unrelated if it occurs through natural causes - and it may be more related to parental discord and intentional separation of parent from child. Deprivation of love may be an important psychological risk factor in the background of depressive disorders. Bereavement in the elderly is a life event with significant consequences for personal health. Local resources, official and voluntary, are employed in crisis intervention to avert disaster, such as suicide. An interesting problem is the case of the demented spouse who functions reasonably well before the death of the supervising partner, only to need institutional care immediately thereafter. It has been recognised for many years now that the mortality rate rises steeply among the bereaved during the first 6-12 months after bereavement. Rahe, in the 1960s, found that the death of a spouse was regarded as possibly the most stressful of life events. Bereavement may be associated with increased adrenocortical activity and increased serum prolactin and growth hormone levels.
When there was a large conference on allergy in the beginning of the eighties in Britain buy discount finast on-line hair loss keranique, I sent a public letter to everyone cheap finast 5 mg on-line hair loss treatment dubai. I was at that time leading the most productive French allergy research group and I was not even invited purchase finast 5mg with amex hair loss cure quotes. As the biggest drug companies moved into immunology and the kudos and money attached to finding cures for asthma and allergy grew, so did the anger and resentment against Jacques Benveniste. He found that his discoveries were often deprecated by the scientific establishment and he was not recognised for them. For example, in asthma research, during the seventies, medical research workers promoted very heavily in papers all over the place, that leukotrienesf were the molecules that did the job. There was enormous interest from the drug companies, who all wanted to get involved. Ten years later, it is clear that leukotrienes have only a modest importance in asthma treatment. Benveniste feels that throughout the eighties he was excluded and isolated from the discussions around his own work and discoveries. According to Maddox, the conclusions of the paper struck at the roots of two centuries of observation and rationalization of physical phenomena. While he was working for Boiron, Benveniste was also working on contracts for mainstream pharmaceutical companies. In 1989, two other homoeopathic companies took over from Boiron, one French, Dolisos, and the other, Homint, half-German and half-Dutch. The first problem that Benveniste encountered with his work came in 1985, when interim results were leaked and then taken up in a full-page article in Le Monde. Although he had no means of knowing it, this attack was the first skirmish in a war declared upon him by a then unknown enemy. The question stripped him of his experience, his advanced knowledge in the field and his status as an internationally renowned scientist. Benveniste was not able within the parameters of the discussion to outline his expert experience. Most scientists consider the control to be one of the essential components of correct research method. It was during that programme that Benveniste realised that he was going to meet some hard opposition to his work. More than anything, he was amazed by the vehemence of the argument used against him. Being a reasonable man and an intellectual, he had expected a debate, not the kind of anger which was now hurled at him. He felt, he says, like a European intellectual who, on visiting a Muslim country, had denied the existence of God. To Benveniste, this attitude was antipathetic to science or any kind of intellectual discourse. I can not understand that scientific data is important enough for everyone to get on their feet and start a bloody war. At the same time he submitted papers to the British Journal of Clinical Pharmacology and the European Journal of Pharmacology. Both the latter articles were eventually accepted and published in 1988 and 5 1987. There were a few questions before publication about the way the statistics were handled. Benveniste got no answer from Nature until a year after he had submitted the paper. The next communication from Nature was a demand that he should arrange for the work upon which the paper was based to be reproduced in other laboratories before publication. Such a principle, if it were put into effect universally, would make the whole scientific process unworkable. Believing that he had become involved against his will in a struggle not only to preserve his own good name, but to defend the objective basis of scientific research, Benveniste agreed to the demand. He found two laboratories, one in Israel and one in Canada, which willingly replicated his work and his results. A team from Italy also replicated the work, doing eight experiments, of which they were happy with seven. All the results were then sent to Nature in the summer of 1987, with the revised paper signed by all the scientists who had carried out the work. In the first quarter of 1988, John Maddox faxed Benveniste with a peer review of the first paper he had submitted eighteen months previously. This was the first time Benveniste had seen this review, and its two pages of comments struck him as a joke. Then, on June 15th 1988, Benveniste received another alarming fax which told him that the paper would be published with an editorial reservation only if he agreed to a team visiting his lab to monitor his work. Sick of the whole dilemma, but completely sure of his scientific work, Benveniste accepted. He imagined that the team would check the laboratory books and see that his experiment had been carried out properly. After all, that was the internationally recognised manner for dealing with such situations. If Jacques Benveniste had expected the investigators to be top-flight scientists, he was disappointed. An ex-performing magician, Randi had dedicated the last twenty years of his life to attacking the work of scientists in the area of psychic research. Although Benveniste did not know it at the time, Randi was an implacable opponent of homoeopathy. John Maddox, who was himself the third member of the team, was in no sense independent. Though held in high regard by the scientific community, he had for a long time been opposed to research which conflicted with the accepted scientific orthodoxy. Here was a man whom he knew as an honourable scientist, acting in opposition to all scientific principles. Benveniste says of his visit: I had in my lab one of the men with the highest position in science, John Maddox. I was in the position of a man who meets the Pope and the Pope asks for his wallet, what was I to do? Having agreed to the visit, Benveniste turned over his laboratory, his records and his staff to assist the three strangers in their replication of his work. Unskilled in the particular area of work, unfamiliar with the lab and insistent upon much gratuitous ballyhoo, the visitors made a terrible mess. Randi introduced a bit of theatre into the proceedings when he wrote down the code that could identify the true samples from the controls, and put it in an envelope which he stuck to the 7 ceiling. It was a ruse to see whether anyone would attempt to tamper with it during the night. We must not let, at any price, fear, blackmail, anonymous l2 accusation, libel and deceit nest in our labs. The number of fifty previous studies was quoted by Denis MacEoin in the Journal of 13 Alternative and Complementary Medicine.
Brody who was the Director Bendann-Iliff Professorship in Ophthal- of the Department of Radiology from 1987- mology : Nicholas T discount finast 5mg with mastercard hair loss cure genetic. Brody was appointed Pres- Funding provided by Constance purchase cheapest finast and finast hair loss cure tips, Maurice finast 5mg otc hair loss cure for pcos, ident of the Johns Hopkins University. Bernheim Research Pro- in the Division of Hand Surgery : fessorship in Surgery : James Black, Thomas M. Thornhill to provide faculty support in the by members of the Bernheim family to honor Division of Hand Surgery, Department of Bertram M. Professorship for of the faculty of the Department of Surgery, Alimentary Tract Diseases in the Depart- he was responsible for pioneering research ment of Surgery  Richard D. Neurosurgery : Benjamin Carson, Funding for this Chair was by contributions M. Alfred Blalock Funding for this professorship was provided was Director of the Department of Surgery by Mr. Tom Clancy Professorship in Ophthalmol- Funding for this Chair was provided by the ogy : Unoccupied. McCarthy-Cooper Estate, patients, and resi- Funding for this professorship was provided dents of Dr. Bordley, who was Direc- by Tom Clancy, a friend of Johns Hopkins tor of the Department of Otolaryngology for Medicine and Johns Hopkins Board of Visi- 17 years (1952-1969). Clayton Professorship in Oncology : Boury Professorship in Molecular Biology Bert Vogelstein, M. Clayton of This Professorship was funded by a bequest Houston, Texas created the Clayton Fund in the will of Mr. Boury which was used to support projects in car- was a native of Baltimore who moved to New diovascular disease under the direction of Dr. Breast Cancer Research Professorship in Professorship in the Clinical Care and Oncology : Occupied by Vered Stea- Research of Pediatric Endocrinology rns, M. Plotnick’s retirement, the name Richard Bennett Darnall Chair in Surgery of the endowed professorship will become : Unoccupied. Professorship in Funding provided by a bequest in the will the Clinical Care and Research of Pediatric of Mrs. Richard Bennett Darnall Professor Emeri- Funding provided from the bequest of Mrs. Funding provided by the estate of Admiral Funding provided by a bequest in the will of Conner. DeLamar, who was born in the chair shall be the Director of the Harriet Holland in 1843 and came to America after the Lane Clinic. On the advice of Funding provided from income from the prin- his attorney, he divided his $30 million estate cipal which will be used “in honor of Dr. David between the “three best medical schools of the Hellmann and that the holder of the chair be day -Johns Hopkins, Harvard and Columbia”. Cudahy, the Funding provided by contributions of current founder of Marquette Electonics, which pro- and former faculty, fellows, and house staff duces medical, diagnostic, monitoring and of the Department of Radiology. Otolaryngology - Head and Neck Surgery Clarence Doodeman Professorship in : Unoccupied. Funding provided by Edward and Loretta Harvey Cushing Professorship in Neuro- Downey to honor Mrs. Funding provided by the Eccles Foundation Firor as a fne surgeon, teacher, and humani- and by Mrs. Edgerton Endowment in Pediatric Epilepsy : for an endowed professorship for the Director Unoccupied of the Department of Plastic and Reconstruc- Funding will be used for pediatric epilepsy. Jonas Friedenwald Professorship in Oph- Doctor Dorothy Edwards Professorship in thalmology : Unoccupied. Gynecology and Obstetrics : Harold Named for father of experimental ophthalmic E. Fries Professorship in Medicine Edwards, who attended the Johns Hopkins : Unoccupied School of Medicine from 1917-1921. Funding provided by the Garrett Fund for the Eudowood Professorship in Pediatric Immu- surgical treatment of children founded by nology : Jerry A. Eudowood was the name of a tubercu- losis hospital offcially known as The Hospital William Thomas Gerrard, Mario Anthony for Consumptives of Maryland, which joined Duhon and Jennifer and John Chalsty with other institutions to form the Children’s Professorship in Urology : William B. King Fahd Chair in Molecular Medicine Given Foundation Professorship in Pedi- : Andrew P. Funding provided by the Kingdom of Saudi Funding provided by the Irene Heinz Given Arabia. The King Fahd Professorships in the and John LaPoute Given Foundation of New School of Medicine represent “an indication of York for the purposes of medical research and the mutual human interest and mutual support teaching. Goldberg Professorship in Oph- King Fahd Chair in Pediatric Oncology thalmology : Ran Zeimer, M. Professorship sorship in Ophthalmology : Michael : William Baumgartner, M. Funding provided by various residents, Established by Robert and Maureen Fedu- patients and friends of Vincent L. Green Professorship in Macular Bayard Halsted Professorship in Cell Biol- Degeneration and Other Retinal Diseases ogy and Anatomy : Unoccupied. Funding provided by a bequest in the will of Funding provided by a bequest from Joseph Mr. Richard Green Professorship of Oph- nature, causes, means of prevention, and thalmology : Richard D. Brain Science Institute : Jeffrey Roth- Funding provided by Department of Surgery’s stein, M. Income from the principal will be used to pro- Jacob Handelsman Professorship in Sur- vide faculty support and “advance the work gery : Michael A. McGehee Harvey and diverse neurosciences community, while Chair in The History of Medicine : making decisions effciently and moving tar- Occupied by Harry M. Medicine, and many friends and relatives of Funding for this professorship was provided the Harveys. Burton Grossman to ensure in the Department of the History of Medicine the integration of the progression of specifc to recognize Dr. Harvey’s (class of 1934) sec- ophthalmologic diseases and to develop ond interest in history after 27 years as Direc- techniques for preventing these diseases. Willard and Lillian Hackerman Professor- Funding provided by a commitment made in ship in Oncology : Moody D. Hagen Professorship in Ophthal- Sherlock Hibbs/Eugene VanDyke Profes- mology : Unoccupied.
The Macklin effect: a fre- The shuttle (6 min) walk distance was not predictive of a poor quent etiology for pneumomediastinum in severe blunt surgical outcome order finast 5mg fast delivery hair loss cats. Chest 2002; 121:1269–1277 dysfunction after cardiac operations: electrophysiologic This article reviews the associated physiologic buy finast with a mastercard hair loss in men 50s fashion, biochemical safe finast 5mg hair loss in neutered male cats, evaluation of risk factors. Perioperative predictors of extubation associated with this complication by logistic regression analy- failure and the effect on clinical outcome after cardiac sis was the use of cardioplegic ice slush. Postoperative pulmonary dysfunction resulting in failure to wean from mechanical ventilator in adults after cardiac surgery with cardiopulmonary support after coronary artery bypass surgery. Med 1990; 18:499–501 Am J Crit Care 2004; 13:384–393 Report of four patients who had diaphragmatic ﬂutter after A nursing review that is worth reading with 159 references. Symptomatic persistent necrosis factor gene polymorphisms and prolonged postcoronary artery bypass graft pleural effusions mechanical ventilation after coronary artery bypass requiring operative treatment: clinical and histologic surgery. Clinical relevance of The effusions were lymphocytic ( 80% lymphocytes) and often angiotensin-converting enzyme gene polymorphisms to resulted in ﬁbrosis and occasional trapped lungs. Thorax 1990; 45:465–468 922–927 Thoracic wall discoordination was documented by magnetom- The presence of a speciﬁc haplotype in the promoter region of eters in 9 of 16 patients 1 week postoperatively. Key words: circadian rhythm; polysomnography; sleep; sleep deprivation; sleep homeostasis; sleep physiology Sleep-Wake Regulation Two basic intrinsic components interact to regulate the timing and consolidation of sleep and Sleep is a complex reversible state characterized wake: sleep homeostasis, which is dependent on by both behavioral quiescence and diminished the sleep-wake cycle, and circadian rhythm, which responsiveness to external stimuli. Neuroscience of Sleep Sleep homeostasis is defined as increasing sleep pressure related to the duration of previous Neural systems generating wakefulness wakefulness: the longer a person is awake, the include the ascending reticular formation in the sleepier one becomes. In con- (wake-maintenance zones), namely in the late trast, only metabolic control is present during morning and early evening; there are also two sleep. Compared with levels during wakefulness, circadian troughs in alertness (increased sleep there is a decrease in both Pao and arterial oxygen 2 propensity) in the early morning and early saturation (Sao ) and an increase in Paco during 2 2 midafternoon. Retinal photoreceptors are most acterized by periodic breathing, with episodes of sensitive to shorter-wavelength light (450 to 500 hypopnea and hyperpnea. Nocturnal sleep typically occurs dur- of others decrease during sleep (eg, cortisol, insulin, ing the decreasing phase of the temperature and thyroid-stimulating hormone). Several physiologic parameters become increased during sleep deprivation, including subjective and objective sleepiness, sympathetic Musculoskeletal System activity, insulin resistance, and levels of cortisol and ghrelin. Two patterns of eye move- current and direct current ampliﬁers and ﬁlters that ments can often be seen: slow rolling eye move- are used to record physiologic variables during ments that occur during drowsiness when eyes are sleep. Derivation consists voltage between two electrodes and can either be of one electrode below and one electrode above the bipolar, ie, when two standard electrodes are mandible. With nasal air pressure of the brain (F [frontal], C [central], O [occipital], monitoring, inspiratory ﬂow signals show a pla- and M [mastoid]), and a numerical subscript, with teau (ﬂattening) with obstructive events or reduced odd numbers representing left-sided electrodes, but rounded signal with central events. Event precedes an Polysomnographic features of many primary arousal, and does not meet criteria for either sleep, medical, neurologic and psychiatric disor- apneas or hypopneas. Smoking is not allowed medications, whereas the low sleep input pattern prior to each nap trial, and persons should not often accompanies disorders presenting with drink caffeine or engage in vigorous physical insomnia or use of stimulant medications. Epworth Sleepiness Scale The multiple sleep latency test consists of 4 or 5 nap opportunities performed every 2 h, The degree of sleepiness is often subjectively with each nap trial lasting 20 min in duration. Sleep onset latency out a break, (e) lying down to rest in the afternoon, is recorded as 20 min if no sleep occurs during (f) sitting and talking to someone, (g) sitting quietly a nap trial. Each nap trial is terminated after 20 after lunch without drinking alcohol, and min if no sleep is recorded; if sleep is noted, the (h) stopped in a car for a few minutes in trafﬁc. Practice parameters disorders, including dementia and Parkinson for clinical use of the multiple sleep latency test disease; psychiatric disorders, such as depression; and the maintenance of wakefulness test. Air- despite the presence of respiratory efforts caused way size is also inﬂuenced by lung volume, which by partial or complete upper-airway occlusion 1 decreases during sleep. Complex sleep apnea is characterized by sites of upper-airway obstruction are behind the central apneas that develop or become more palate (retropalatal), behind the tongue (retrolin- frequent during continuous positive airway gual), or both. Hormone- ory); erectile dysfunction; gastroesophageal reﬂux; replacement therapy has been suggested for post- nocturia; driving and work-related accidents; menopausal women; however, data regarding its impaired school and work performance; and efﬁcacy for this indication are inconsistent. Finally, noninva- as the result of aerophagia; or chest discomfort and sive positive pressure ventilation is indicated for tightness, many of which may result in the patient cases of persistent sleep-related hypoventilation discontinuing therapy. Factors oral devices; and tongue-retaining devices which, predicting the need for heated humidification by securing the tongue in a soft bulb located ante- include the following: (1) age 60 years, (2) use of rior to the teeth, hold the tongue in an anterior drying medications, (3) presence of chronic muco- position. In addition, mandibular reposi- should be considered whenever there is doubt tioners should not be used in persons with inad- about a person’s degree of sleepiness. Nasal septo- resistance accompanied by increased or constant plasty, polyp removal, and turbinectomy are used respiratory effort and arousals from sleep. Uvulopalatopharyngoglossoplasty and arousals and are followed by less negative esoph- maxillomandibular advancement increase the ret- ageal pressure excursions as airflow increases rolingual, retropalatal, and transpalatal airway. Nasal pressure monitoring dem- Finally, tracheotomy can be used to bypass the onstrates inspiratory flattening followed by a narrow upper airway and is the only surgical pro- rounded contour during arousals. Practice hypoventilation developing during sleep, includ- parameters for the use of autotitrating continuous ing a decrease in minute ventilation and/or tidal positive airway pressure devices for titrating pres- volume, abnormal ventilation/perfusion relation- sures and treating adult patients with obstructive ships, or changes in ventilatory chemosensitivity sleep apnea syndrome: An update for 2007. Key words: circadian rhythm sleep disorders; insomnia; nar- colepsy; parasomnias; restless legs syndrome; sleepiness Insomnia Insomnia is characterized by repeated difﬁculty with either falling or staying asleep that is associ- The differential diagnoses of excessive sleepiness 1 ated with impairment of daytime function. Persons with insomnia have an increased risk Likewise, there is no daytime napping or impair- of psychiatric illness developing, such as major ment of daytime functioning. Other consequences of insomnia include fatigue, cognitive impairment, impaired academic Psychophysiologic Insomnia and occupational performance, diminished quality of life, and greater health-care utilization. Causes Classifcation consist of rumination and intrusive thoughts, increased agitation and muscle tone, and learned Forms of insomnia can be classiﬁed, based on maladaptive sleep-preventing behavior, such as duration of sleep disturbance, as transient if the excessive anxiety about the inability to sleep. Another useful distinction person’s own bed and bedroom, with better sleep classiﬁes the causes of sleep disturbance into pri- being described when attempted in another mary or comorbid insomnia. In this syndrome, sleep disturbance is a result Common Medications That Can Cause of an identiﬁable acute stressor, such as a momen- Insomnia tous life event, change in the sleep environment, or an acute illness. Sleep improves with resolution Many medications can cause insomnia; the of acute stressor or when adaptation to the stressor most common include antidepressants such as develops. Short-acting niques address both somatic and cognitive hyper- agents are usually used for sleep-onset insomnia, arousal and reduce them by progressive muscle intermediate-acting agents for concurrent sleep- relaxation (ie, sequential tensing and relaxing of onset and sleep-maintenance insomnia, and long- various muscle groups), biofeedback, or guided acting and extra-long-acting agents for early imagery. Many adverse effects are associated with the Stimulus control strengthens the association of use of benzodiazepines, including (1) rebound bedroom and bedtime to a conditioned response daytime anxiety, especially with short-acting for sleep. Patients are instructed to use the bed only agents; (2) residual daytime sleepiness with long- for sleep or sex, lie down to sleep only when sleepy, acting agents; (3) cognitive and psychomotor get out of bed and go to another room if unable to impairment; (4) development of tolerance deﬁned fall asleep, engage in a restful activity, and return as the need for increasingly higher dosages to to bed only when sleepy. Duration of action varies, with zaleplon accidents, impaired work and academic perfor- having the shortest, zolpidem having an interme- mance, and mood disorder. Compared with conventional insufﬁcient sleep syndrome, idiopathic hypersom- benzodiazepines, this class of agents have a similar nia, and recurrent hypersomnia. Sleepiness can hypnotic action; possess no muscle relaxant, anti- also be caused by a variety of medical disorders or convulsant, or anxiolytic properties; and are by drugs or substance use. Ramelteon is a melatonin receptor agonist with Narcolepsy is a neurologic disorder character- selectivity for the suprachiasmatic nucleus mela- ized by the clinical tetrad of excessive sleepiness, tonin receptor. It can manifest as brief naps, each lasting Other hypnotic agents include trazodone, tri- about 10 to 20 min, that occur repeatedly through- cyclic antidepressants, ﬁrst-generation histamine out the day. The ﬁrst- hallucinations that may be visual, auditory, tactile generation histamine antagonists, including or kinetic, occurring at sleep onset (hypnagogic), diphenhydramine, constitute the majority of over- or occurring on awakening (hypnopompic). Adverse effects of hallucinations may be accompanied by sleep ﬁrst-generation histamine antagonists consist of paralysis, which could also be either hypnagogic, rapid development of tolerance; residual daytime hypnopompic, or both. Sleep paralysis generally sedation as the result of long half-life; and anti- lasts a few seconds or minutes, affects voluntary cholinergic effects (eg, confusion, delirium, dry muscles, and spares the respiratory, oculomotor mouth, and urinary retention).