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By W. Darmok. California Institute of the Arts. 2018.

Lippmann also served as Adjunct Orthopedic Surgeon and Associate Orthopedic Surgeon at Montefiore Hospital cheap 80mg diovan otc hypertension code for icd 9. At Montefiore he became Chief of Service in 1938 diovan 80mg with amex blood pressure medication viagra, but resigned in 1942, 3 years after he became Director of the Department of Orthopedic Surgery and Orthopedic Surgeon-in- Chief at Mount Sinai Hospital. Lippmann served as Orthopedic Surgeon-in-Chief for almost 30 years at Blythedale, a long-term children’s care hospital in Valhalla, New York, and at the 196 Who’s Who in Orthopedics time of his death was Director Emeritus of Ortho- his scientific inquiry and teaching, his sense of pedics, and Emeritus Professor of the Department humanity and the ethical code manifest in his of Orthopedics of Mount Sinai School of practice and in his approach to patients formed Medicine. Lippmann was a superb craftsman, capable great influence on the growth of the hospital as a of translating his mechanical concepts into reality. In his office was a workshop with power tools and Until his untimely and sudden death on June 9, a lathe to work out the designs of devices that 1969, at the age of 70, Dr. Robert Korn Lippmann were later fabricated, or new instruments to was actively engaged in orthopedic practice. Among his many original Lippmann was survived by his wife, his daugh- contributions were the first compression bolt for ter, Mrs. Lippmann Orthopedic Research Laboratory at Mount Sinai was established in 1965 in his honor. Lippmann participated in community, national, and interna- tional orthopedics. He was a Fellow of the New York Academy of Medicine, serving as secretary (1949–1950) and chairman (1950–1951) of the orthopedic section, and as a member of the advi- sory committee (1951–1956). He was a Fellow of the American College of Surgeons (1932), serving as a member of its New York and Brooklyn Regional Fracture Committee (1949). He was a Fellow of the American Academy of Orthopedic Surgeons (1932) and a member of the American Orthopedic Association (1954), the Orthopedic Research Society (1959), and the Joseph LISTER Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) (1957). Lippmann developed a spirit of cooperation and dedication on the Mount Sinai Orthopedic Joseph Lister was born at Upton House, Essex, on Service. For generations his family had agreements, and thorough exploration of clinical belonged to the Society of Friends and the early problems. These were his basic techniques in influence of this body continued to govern his resident-training. He had considerable success in back of his mind was always the idea that he business in the city and somehow managed in his would some day describe the principles of con- leisure to acquire a worldwide reputation for his servative orthopedics that he taught—a task that researches in optics, which led to the perfection must be completed by his students. He also collab- many contacts with the residents and staff, orated with Thomas Hodgkin in the publication particularly at the monthly evening journal club of papers on microscopic observations of meetings at their home in New York and at their blood and animal tissues. Lippmann’s it may be gathered that the young Lister was born service and leadership over a period of 43 years, into an environment highly favorable for the 197 Who’s Who in Orthopedics pursuit of science; and in his great quest he was less ridicule. Morton, whom destined to gaze at the amazing new world of Wells taught, succeeded in inducing anesthesia microorganisms through an apparatus perfected while J. On December 21 of the same year, Robert he showed an early taste for natural science and Liston at University College Hospital carried out which led to his choice of medicine as a career. Hospital, London, where he took his BA degree This was a memorable time—the birth of a new before proceeding to professional training. He epoch in surgery—days to which men would look proved himself a brilliant student, occupied a back. No longer need a patient be terrified at the leading place in his own school, and took honors whisper of an operation, nor a surgeon be called at the university examinations. Anes- Sharpey were inspiring teachers, who at that time thesia promoted adventure; but sometimes sadly were laying the foundations upon which a disastrous adventure; the patient survived the succession of great investigators built a school of operation but risked death from later gangrene or physiology at University College, which became sepsis. Both these men taught him the might be, he was, in the words of Volkmann, scientific method of research. Wharton Jones, a “Like a husbandman, who having sown his field prolific worker, was interested in the mechanism waits with resignation for what the harvest might of the circulatory system and the stages of inflam- bring, and reaps it fully conscious of his own mation; for his investigations he used the frog’s impotence against the elemental powers which web and the bat’s wing. Lister undoubtedly owed may pour down on him rain, hurricane, and much to this master of research; he copied his hailstorm. Sharpey was both friend and At the proper time Lister qualified with the MB teacher to Lister and it was he who commended (London) and was appointed house physician and him to Syme. In 1852 he gained the FRCS Inspired by these two men, Lister, while yet an (England) and the next year went to Edinburgh undergraduate, carried out original work on the with an introduction to Syme. Kölliker surgeon received him cordially and there began a had discovered that the iris consisted of involun- friendship between them that the years increased. This particular work became his house surgeon, reported his lectures attracted considerable attention and led to a firm to the Lancet, and was a most enthusiastic pupil, friendship between the two observers that lasted eventually marrying his eldest daughter Agnes.

Though this comparison was designed to reinforce the pernicious character of nicotine generic diovan 160mg blood pressure medication good or bad, it also implicitly undermined the wider concept of addiction: after all generic diovan 40 mg fast delivery hypertension stage 1, if millions of people have managed to quit smoking and overcome the demon nicotine, perhaps the grip of heroin and cocaine is not quite the overwhelming compulsion it is often made out to be. For the anti-smoking campaign, labelling nicotine as addictive is crucial to its challenge to the tobacco industry’s insistence on 109 THE EXPANSION OF HEALTH ‘consumer sovereignty’, on the freedom of the individual to choose whether or not to buy cigarettes. As the RCP put it, ‘if smoking and nicotine are addictive, the argument that the individual adult consumer has the right to choose to purchase and use tobacco products, and that the tobacco industry has the right to continue to supply them, is difficult to sustain’ (RCP 2000:101). If the smoker is the victim of a chemical dependency, and cigarettes are delivery systems for this chemical, then the government should regulate the supply and distribution of cigarettes as it would any other dangerous drug. Though the anti-smoking lobby plays up its offensive against the tobacco industry (whose executives are now despised and demonised as though they were war criminals or child abusers) its real threat is to the status of the individual and to civil liberties. If people who smoke—more than a quarter of the adult population— are defined as being in a state of drug addiction and are considered as a result to be incapable of making rational decisions, then the state is justified in taking ever greater control over their behaviour. The dominant theme in the earlier medical literature was that cigarette smoking was merely a bad habit. That this habit could be broken by an effort of will was confirmed by the rapid response of an informed public to the revelations of the link between cigarettes and lung cancer. As we saw in Chapter 3, publicity about the dangers of smoking following the RCP’s 1962 report led to a steady decline in levels of smoking. In a chapter devoted to ‘the smoking habit’, the second edition of the RCP report acknowledged discussion of ‘pharmacological dependence’ on nicotine (RCP 1971: 112) Though it suggested that this matter required further research, its general tone was dismissive: ‘evidence that the difficulty that many smokers find in giving up the habit is due to habituation to nicotine is scanty’ (RCP 1971:41). In the course of the 1960s and 1970s a wide range of programmes, using everything from behavioural and psychodynamic therapies to hypnotism and acupuncture, were established in the effort to encourage people to quit smoking. A review of these programmes in the USA in 1982 drew gloomy conclusions: 1 No one cessation technique or approach is clearly superior to any other; 2 Most people who join cessation programmes do not quit smoking; 110 THE EXPANSION OF HEALTH 3 Of those who do quit, most do not remain off cigarettes for any substantial period of time. In the course of the 1980s, the recognition of nicotine addiction allowed for the convergence of different forms of dependence in the concept of ‘substance abuse’, or in the less judgemental term increasingly favoured in medical circles, ‘substance misuse’. This provided a useful umbrella to cover not only alcohol, heroin and nicotine, but other illicit ‘substances’—such as cannabis, solvents, cocaine/crack, amphetamines, LSD and ecstasy, and others—which were in widespread use, but for which the evidence of ‘dependency’ was weak. Indeed they needed ‘nicotine replacement therapy’, a formulation paying richly ironic homage to the use of ‘hormone replacement therapy’ in post-menopausal women. A blood nicotine assay had become available for research purposes and nicotine chewing gum came on the market. In 1988 the US Surgeon-General’s report gave official approval to nicotine addiction as a condition requiring appropriate medical treatment (Berridge 1998). In Britain, however, some medical resistance to the concept of ‘nicotine replacement therapy’ was reflected in the decision not to make it available on prescription, either in the form of chewing gum or the more ‘medical’ skin patches. It was not until 1998 that an editorial in the BMJ called for ‘nicotine replacement therapy for a healthier nation’—and proposed that it should be made available on prescription (Smeeth, Fowler 1998). This demand was issued with the full authority of a Cochrane Library ‘systematic review’ of 47 trials involving more than 23,000 patients, claiming to demonstrate its efficacy (Silagy et al. However, patients in these trials were only followed up for 6–12 months, so whether the effect is sustained remains unknown—as does whether this approach would also be effective when extended to a wider, and inevitably less motivated population. Nevertheless the nicotine replacement bandwagon was on the roll, and, following the RCP’s enthusiastic endorsement, it seems set to allow the further medicalisation of individual behaviour. The roots of this movement, the subject of a penetrating study by John Steadman Rice, lie in the ‘Twelve Step’ recovery programme popularised by Alcoholics Anonymous (founded in Ohio in 1935, AA became widely established in the USA and internationally in the post-war period) (Steadman Rice 1998). Though groups concerned with the special problems of the spouses and families of alcoholics had long run in parallel with the mainstream AA meetings, in the 1980s there was a dramatic proliferation of such groups. They now rapidly expanded to include ‘survivors’ of other forms of victimisation (domestic violence, sexual abuse) and victims of other forms of addiction, such as gambling, shopping, sex. The central claim of this movement was that ‘co-dependency’ was a disease, an addiction, characterised by dependence on a pathological relationship with another person, a substance, or any ‘processes external to the individual’ (Steadman Rice 1998). Co-dependents are believed to experience ‘a pattern of painful dependence on compulsive behaviours and on approval from others in an attempt to find safety, self worth and identity’. As Steadman Rice observes, this is a concept of ‘virtually limitless applicability’ and it was not surprising to find it extending to cover, not only familiar bad habits, but even fads about novelties such as the internet, mobile phones and the National Lottery (all of which were linked with media scare stories about new forms of addiction in the late 1990s). The inevitable result was inflated estimates of the numbers of victims of various addictions: one (US) estimate reckoned that co-dependency afflicted ‘approximately 96 per cent of the population’ (Steadman Rice 1998) Lest this be thought to be a preoccupation peculiar to Americans, the British advocacy group Action on Addiction claims that ‘almost every one of us has either experienced some form of addiction or knows someone who has’ (AOA 1997). With typically British modesty it settles for the assertion that ‘in fact, one in three adults suffer from some form of addiction’. While co-dependency expanded the concept of addiction to cover diverse personal and social problems, there was also a surge in the popularity of biological theories of addiction. Developments in genetics (not only a ‘gene for alcoholism’, but also a ‘promiscuity 112 THE EXPANSION OF HEALTH gene’), advances in the study of neurotransmitters (endorphins, serotonin, dopamine) and the speculations of evolutionary psychologists were all recruited to explain the remarkable grip of compulsions and addictions on individuals in modern society (James 1997).

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The basic picture which emerges for CVD diamond growth is believed to be as follows purchase 160mg diovan free shipping heart arrhythmia 4 year old. During growth purchase diovan 80 mg with mastercard blood pressure zap nerves, the diamond surface is nearly fully saturated with hydro- gen. This coverage limits the number of sites where hydrocarbon species (probably CH3) may stick. A schematic illustration of the resulting pro- cesses is shown in Figure 5. In oxygen-containing gas mixtures, it is believed that the hydroxyl (OH) radical plays a similar role to atomic hydrogen, except that it is more effec- tive at removing graphitic carbon, leading to higher growth rates and better quality films at lower temperatures. A schematic illustration of the reaction process occurring at the diamond surface. Atomic hydrogen removes a surface hydrogen to form an H2 molecule, leaving behind a reactive surface site (illustrated by the dot). The most likely fate for this surface site is for it to react with another nearby hydrogen atom, returning the surface to its previous stable situation. However, occasionally a gas phase CH3 radical can collide and react with the surface site, effectively adding one carbon to the structure. This process of hydrogen removal and methyl addition may then occur on a site adjacent to the attached methyl. Further hydrogen removal reactions will lead to completion of the ring structure, locking the two carbons into the diamond structure. Thus, diamond growth can be considered to be a one-by-one addition of carbon atoms to the existing diamond structure, catalysed by the presence of excess atomic hydrogen. However, this is by no means the only possible substrate material – although any candidates for diamond growth must satisfy a number of important criteria. One requirement is obvious – the substrate must have a melting point higher than the temperature required for diamond growth (normally 700°C). This precludes the use of existing CVD techniques to coat low-melting point materials, like plastics, alumin- ium, some glasses, and electronic materials such as gallium arsenide. Another criterion is that the substrate material should expand by the same amount as diamond when heated. This is because at the high growth temperatures currently used, a substrate will tend to expand, and thus the diamond coating will be grown upon, and bonded directly to, an expanded substrate. Upon cooling, the substrate will contract back to its room tem- perature size, whereas the diamond coating will be relatively unaffected by the temperature change. Thus, the diamond film will experience signifi- cant compressive stresses from the shrinking substrate, leading to bowing of the sample, and/or cracking and flaking of the entire film. Another issue is that at the high deposition temperatures many sub- strate materials react with carbon directly to form a carbide. The presence of a thin carbide layer is not a problem – in fact it is desirable, since the carbide layer can be pictured as the ‘glue’ which aids the adhesion of the diamond layer by (partial) relief of stresses at the interface. Without this carbide glue, any diamond layer will not adhere well to the surface, and the films will often readily delaminate after deposition. This can be utilised as one method to make free-standing diamond films, using non-carbide- forming substrate materials such as copper, tin, silver and gold. Conversely, if the substrate material is too reactive toward carbon, then the deposited carbon (even when it’s in the form of diamond) simply dis- solves into the surface forming a solid solution. This can result in large quantities of carbon being transported into the bulk, rather than remain- ing at the surface where it can promote diamond growth. The latter metal is of par- ticular concern, because this means that at present all industrially impor- tant ferrous materials (such as iron and stainless steel) cannot be diamond coated using simple CVD methods. Electron micrographs of different types of diamond film grown on silicon. The white bar shows the scale in micrometres ( m) (thousandths of a millimetre). MAY It is apparent that many of the problems with expansion mismatch and carbon solubility could be eliminated if the deposition were to occur at much lower temperatures. Many groups world-wide are focusing their research efforts in this direction, and the answer may lie in different gas chemistries, such as use of carbon dioxide or halogen containing gas mix- tures. Until then, the difficulties associated with diamond growth on prob- lematic materials have ensured the continuing popularity of silicon as a substrate material.

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Within a couple of months after the onset and because the pain only affected him at night generic 160 mg diovan with amex pulse pressure 53, Dr cheap diovan 160 mg on line hypertension over the counter medication. He started taking sleeping pills and eventually developed an addiction to them. Pitman allowed a urologist to convince him to have a partial prostatectomy. After suffering many more months, another urologist almost convinced him to have the remainder of his prostate removed. But something told him to stop looking at the problem from the surgical perspective and view it from a holistic medical perspective instead. Pitman decided it was finally time to take matters into his own hands, even though urology was not his field of expertise. He engaged in some research at the hospital library as well as on the Internet. This led him to consider that he might have a hormonal problem, so he sought the help of an endocrinologist. Like the urologists before him, the endocrinologist had never heard of this particular mystery malady. However, he had heard about our Eight Steps to Self-Diagnosis and advised Dr. Painful Erections • Quality and Character: These erections are very hard and unrelenting. For my fiftieth birthday, I bought myself a Harley-Davidson and took a trip across several states, much to my wife’s dismay. Except for my cholesterol and triglycerides, which were high, I was in very good health. The doctor told me to lose some weight and to watch my sweets and alcohol intake. He also prescribed cholesterol medication and Rogaine for male pattern baldness. On the other hand, noth- ing seems to make it worse, but it doesn’t stop. Step Four: Do a Family Medical History and Determine If You Have or Had Any Blood Relatives with a Similar Problem. Pitman did what amounted to a medical genealogy chart, which was quite lengthy. This does not appear to be genetic, however, because my cousin’s condition was the result of an inflammation of the urethra. My urologist had already eliminated this as the cause of my problem along with other possible causes, scuch as a reaction to medication used to counteract impo- tence such as Viagra. Step Five: Search for Other Past or Present Mental or Physical Problems. Other than my painful erection problem, I had a cervical sprain after an automobile accident in my twenties, kidney stones several years ago, and now a high cholesterol problem which is currently being treated with med- ication. Could my new lifestyle/hobby—motorcycling—have anything to do with my medical mys- tery? Also, in trying to keep an open mind and thinking about my belief systems, there is a slight possibility that the symptoms do not indicate a dis- ease or condition, which is why I can’t find a diagnosis; maybe they are a side effect of some medication. I have listened to my patients who have from time to time complained about side effects of medications I prescribed, and I dismissed them if I couldn’t find any literature or findings that would sup- port their complaints. Now, since I cannot find a diagnosis for my condi- tion—it’s not in the medical books—I am wondering if I have been too quick to dismiss this issue. Maybe I’d better investigate this further even though I have not seen my condition listed as a side effect. It may not be an independent disease or condition, and my symptoms have to be caused by something! Step Eight: Take Your Notebook to Your Physician and Get a Complete Physical Exam. Pitman a physical exam- ination because they were located in different states, but the endocrinolo- gist and urologists had already done so. Pitman raised two excellent questions that were brought forward as a result of doing the Eight Steps: whether motorcycling could be causing some trauma and possibly be a precipitating cause of his problem, and whether his problem was iatro- genic (medically induced by a medication).

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The onset is in childhood diovan 160mg cheap blood pressure medication dizzy spells, typically between 1 and 8 years with greatest frequency between 3 and 5 years purchase diovan 40mg on line hypertension juice recipe. Seizures most commonly include tonic axial seizures, often nocturnal during non-REM sleep and associated with autonomic phenomena. Frequently described seizures include atonic and tonic seizures resulting in drop attacks, and prolonged atypical absence with automatisms sometimes accompanied by generalized seizures. Other seizure types may occur and predominate, such as in the myoclonic variant, or evolve, such as the increased frequency of generalized tonic–clonic convulsions in adolescence. Seizures usually occur multiple times a day, are usually brief but may be repetitive or prolonged. Tonic or 79 80 Vanderver and Gaillard atypical absence status may occur frequently in some patients. Frequent falls because of repeated seizures are disabling in many children with LGS and may result in injury. Characteristic EEG Findings Electroencephalographic tracings are not diagnostic, as in some epilepsy syndromes, but are characteristic of the diagnosis. The background is abnormal, with lower than age appropriate frequency of the posterior basic rhythm and intrusion of slow activ- ity generally. During wakefulness, generalized, bisynchronous slow spike-and-wave and polyspike-and-wave discharges (1–2. These may occur in bursts or as near continuous activity, and are most often irregular in frequency, distribution, and amplitude. This pattern may be asymmetric and intermixed with bursts of faster activity. Hyperventilation may increase the fre- quency of slow spike-and-wave discharges, but photic stimulation produces no par- oxysmal activation. During sleep, bursts of generalized fast spikes are seen at 10 Hz or more, maximal in non-REM sleep, and are the electrographic correlate of noctur- nal tonic seizures. They may obscure normal sleep architecture and, while not the pattern of electrographic status epilepticus of sleep (ESES), may occupy up to 50% of the recording. Generalized spikes, and in some patients multifocal spikes, can be seen throughout the recording. Neuropsychologic Disturbances Mental retardation is almost universal in LGS, with fewer than 10% of patients pre- serving near-normal intellectual functioning. Children may appear normal or near normal at onset with an abrupt deterioration following the onset of uncontrolled sei- zures, or may have a preceding encephalopathy, including infantile spasms. Overall, cognition progressively deteriorates, compounded by repeated trauma from falls and the effects of multiple anticonvulsants. Behavior problems abound and include autis- tic spectrum disorders, aggressiveness, and hyperactivity. EVALUATION—ETIOLOGY The differentiation of LGS from other catastrophic onset childhood epilepsies is important for prognosis and management. The seizure pattern may not appear char- acteristic initially and suggestive EEG patterns may not appear for several months. Therefore, it is not unreasonable to pursue diagnostic testing that may be suggested by the individual’s presentation—for example, that of progressive myoclonic epi- lepsy in a patient in whom the initial presentation includes myoclonic seizures. Very few patients with LGS, however, have documented abnormalities of metabolism. Concerns that LGS may be related to a developmental channelopathy or be an immune-mediated process have yet to be substantiated. In some series, 17–30% of patients with LGS have a history of infantile spasms. Therefore, central nervous system insults known to predispose to infantile spasms have been implicated in the pathogenesis of LGS. These include congenital infec- tions, sequela of neonatal hypoglycemia, hypoxic–ischemic encephalopathy, and traumatic brain injury. Lennox–Gastaut Syndrome 81 Structural abnormalities are the most common underlying etiology of sympto- matic LGS.

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