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T he effect of educa­ tion on health was illustrated by a National B ureau of Economic Research study that exam ined interstate differen­ tial and age-adjusted death rates purchase flavoxate without a prescription muscle relaxants knee pain. O ne finding was that as large a reduction in mortality is associated with the expendi­ ture of one m ore dollar for education as an additional dollar spent on medical care order flavoxate 200 mg line spasms catheter. Department of Health discount flavoxate 200 mg visa spasms under ribs, Education, and Welfare, Public Health Service, Age Patterns in Medical Care, Illness, and Disability, United States—July, 1963-June, 1965, Series 10, no. In com paring treatm ent, prevention, inform ation, and research, he found that both literacy (as a proxy for inform ation) and potable water (as a proxy for prevention) had high impacts on life expectancy in all nations in the The Impact of Medical Care on Health Status 27 W estern hem isphere. Ginzberg approvingly quotes an earlier report stressing the im portance of nutrition for physical development: a diversified enriched diet will probably contribute to the health of the population. Victor Fuchs, in an unpublished paper, points out that affluence frequendy leads to excessive consum ption, even engorgem ent of some goods, such as rich foods, that adversely affect health. A link between nutrition and health has also been estab­ lished by studies contrasting the impact on health o f nutri­ tion and medical care. In one village, only im proved m edi­ cal care was introduced; in another, only nutrition was enriched; in a third, both medical care and diet were en­ hanced. T he results show that nutrition was far m ore significant in im proving health than the provision o f medical care. In both cases the results, while tentative and crude, tend to prove the worth o f certain disease detection program s. In general, program s that provide increased services for m others and children in areas that have traditionally had few medical services have the greatest payoff. Fluoridation program s, which are relatively in­ expensive, produce benefits (in terms of reduced num bers of cavities) in m ore than 300,000 children for an expendi­ ture o f $10 million. Treatm ent-oriented program s for the same am ount o f money potentially benefit only 18,000 to 44,000 children. No cure is known for schizophrenia, the most prevalent psychosis, although proponents of megavitamin treatm ent profess to have had some success. T he use of tranquilizers and shock therapy has also had some impact on reducing hospitalization rates. T here is, however, some evidence that social and en­ vironm ental factors may play a role. Although not all the studies confirm the hypothesis of the authors, the conclusion is reached that two of the studies “suggest strongly that im provem ent in social environm ent probably does have a favorable effect on mental health. The fact that treatm ent is emphasized over prevention is not entirely the fault of medicine. In the case o f m aternal and child health, fluoridation program s, and other similar program s, the choice o f w hether to fund or not to fund is a political The Im pact of Medical Care on Health Status 29 decision. In this sense the choice of treatm ent over preven­ tion can be said to be a choice made by the public. But, given the power and mystique of medicine, it is also true that the public’s choices about health m atters are strongly influenced by physicians and, to a lesser extent, other health profes­ sionals. Medicine has chosen treatm ent over prevention, and it continues to defend its choice. Prevention program s are starved at least in part because medicine wants too m uch of the loaf. Prevention program s are also starved because medical care is often a “life and death” matter. No argum ents and no logic will convince terrified parents that the resources needed to treat their child would be m ore rationally allocated to prevention. Medicine could do far m ore to inform public opinion, but the problem would remain. This is why I argue, in some detail later, that our basic conceptions about health must change if medicine is to change. T he public’s value preferences are real; only when those value preferences change will medicine change. In combination, then, the empirical evidence and the theory seem convincing; medical care has a limited impact on health and is most effective when applied to certain identifiable conditions where there is evidence about its ef­ fectiveness. But when contrasted with all the other factors that demonstrably affect health, medicine plays a m inor role, despite being cast for lead. The Hippocratic era established the scientific foundation o f medicine four centuries before the Christian era.

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For example order flavoxate 200 mg mastercard spasms after stent removal, haemaglutinin order flavoxate 200mg muscle relaxant 8667, in the influenza virus discount 200mg flavoxate with mastercard muscle relaxant 563 pliva, is activated by a conformational change caused by the acidic conditions which occur when it is taken up inside its host cell and enters the lysosome. Many of the proteins that bind calmodulin are themselves unable to bind calcium, and so use calmodulin as a calcium sensor and signal transducer. Calmodulin undergoes a conformational change upon binding of calcium, which enables it to bind to specific proteins for a specific response. For example: • allosteric changes in enzyme activity occur in milliseconds or less • transmembrane ion channels open or close in milliseconds or less • G-protein transmembrane signalling operates over a few milliseconds • protein kinases and phosphatases operate over a few seconds • a protein switches compartments in a minute or so • changes in gene expression are evident over about 24 hours • growth/differentiation occurs over a few days. Today, commercially purified and sometimes immobilised enzymes are used by industry and medicine. A natural event; the gene for lactase (ß-galactosidase) is ‘switched on’ at birth and ‘switched off’ after weaning. As a result, lactose is unabsorbed by the body, ferments in the lower gut and produces intestinal gases (methane), leading to pain and flatulence. In most Europeans, however, the infant condition persists, and the lactase gene remains active (possibly linked with the domestication of cattle and goats in the Near East some 10 000 years ago; the ability to digest lactose throughout life could have conferred some nutritional advantage). The gene encoding lactase in humans is located on chromosome 1; 70% of ‘Westerners’ have a mutation in the gene such that it fails to ‘switch off’, thus conferring lactose tolerance. For those lactose-intolerant individuals, lactase may be added to milk or taken as capsules before a meal; it is supplied as a pro-enzyme called prolactazyme. The pro-enzyme is activated by partial digestion in the stomach, so that it has the opportunity to function in the small intestine. So-called ‘live yogurts’ solve this problem because the lactose (in the yogurt) is digested by the bacteria present. Lactase enzyme is expensive however; nowadays milk can be pre-treated with lactase before distribution. It is useful for diabetics to measure their blood sugar level throughout the day in order to regulate their use of insulin. One test (Clinistix) relies upon a chemical reaction that produces a colour change on a test strip. The test strip contains a chemical indicator called toluidine and the ‘immobilised’ enzyme glucose oxidase. Glucose oxidase converts the glucose in urine to gluconic acid and hydrogen peroxide; hydrogen peroxide reacts with toluidine, causing the colour change. A variety of metabolic diseases are caused by deficiencies or malfunctions of enzymes, due originally to gene mutation. Albinism, for example, may be caused by the absence of tyrosinase, an enzyme essential for the production of cel- lular pigments. One such example is Gaucher’s disease type I, caused by a deficiency in the enzyme glucocerebrosidase, causing lipids to accumulate, swelling the spleen and liver, and trigger- ing anaemia and low blood platelet counts. Such patients often suffer from fatigue, grossly distended abdomens, joint and bone pain, repeated bone fractures and increased bruising and bleeding. This can be treated using intravenous enzyme replacement therapy with a modified version of the enzyme, known generically as alglucerase. Type I (non-neuropathic type) is the most common; incidence is about 1 in 50 000 live births (particularly common among persons of Ashkenazi Jewish heritage). Ceredase is a citrate buffered solution of alglucerase manufactured from human placental tissue. Streptokinase is administered intravenously to patients as soon as possible after the onset of a heart attack, to dissolve clots in the arteries of the heart wall. Streptokinase belongs to a group of drugs known medically as ‘fibrinolytics’, or colloquially as ‘clotbusters’. It works by stimulating production of a naturally produced protease, plasmin, which degrades fibrin, the major constituent of blood clots. Asparaginase, extracted from bacteria, has proven to be par- ticularly useful for the treatment of acute lymphocytic leukaemia in children, in whom it is administered intravenously. Its action depends upon the fact that tumour cells are deficient in an enzyme called aspartate-ammonia ligase, restricting their ability to synthesise the normally non-essential amino acid L-asparagine. The action of the asparaginase does not affect the functioning of normal cells, which are able to synthesise enough for their own requirements, but reduces the free circulating concentration, thus starving the leukaemic cells. A 60% inci- dence of complete remission has been reported in a study of almost 6000 cases of acute lymphocytic leukaemia.

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Case reports suggest an association between paternal drinking and ‘malformations and cognitive deWciencies’ in the children of alcoholic men (Little and Sing purchase flavoxate online spasms toddler, 1987; Colie discount flavoxate online master card muscle relaxant vicodin, 1993: p discount generic flavoxate canada spasms between shoulder blades. Ricardo Yazigi, Randall Odem and Kenneth Polakoski discovered that cocaine could bind to sperm and thereby be transmitted to the egg during fertilization. Reports of cocaine ‘piggybacking’ on sperm have led to controversy in the scientiWc community over whether this phenomenon could contribute to birth defects (Brachen et al. In animal studies, opiates (such as morphine and methadone) administered to fathers, but not to mothers, have produced birth defects and behavioural abnormalities in the Wrst and second generations of the father’s oVspring (Friedler and Wheeling 1979; Friedler, 1985). Press coverage of male-mediated harm The scientiWc evidence on male-mediated risks has generated quite diVerent stories in popular magazines and newspapers than it has for women. Whilst images of crack babies and irresponsible mothers prevail in stories about maternal exposures to drugs, visual images in popular science magazines and news stories about male reproduction place sperm in the centre of focus as the tiniest victims of toxicity. Even in newspaper stories that address the connection between paternal exposures and fetal health, certain patterns of reporting emerge that function to reduce male culpability for fetal harm. In all of the stories that draw connections between paternal exposures and fetal harm, maternal exposure was also mentioned as a possible source of harm. Evidence of male-mediated risks are often prefaced with statements such as, ‘While doctors are well aware of the eVects that maternal smoking, drinking and exposure to certain drugs can have on the fetus, far less is known about the father’s role in producing healthy oVspring’ (Merewood, 1992: p. News and World Report began an article on paternal–fetal harm in these terms, ‘It is common wisdom that mothers-to-be should steer clear of toxic chemicals that could cause birth defects. Between fathers and fetuses 125 Fourth, paternal exposures to illegal drugs are always contextualized by reference to ‘involuntary’ environmental and workplace exposures, thereby reducing men’s culpability for harm. After reporting that children of fathers who smoke have been found to be at increased risk for leukaemia and lymphoma, the article ends with the recom- mendation of a physician that men who smoke ‘either modify their diets to include fruits and vegetables or take a vitamin C supplement each day’. While sperm ‘delivers’, ‘transports’ or ‘carries’ the drug to the egg in such stories, it never ‘assaults’ the fetus, as stories on drug use and women imply. When the sperm is not presented as itself a victim, it acts as a shield for men – deXecting or capturing the blame that might otherwise be placed on the father. One news story entitled ‘Sperm Under Siege’, presented an image of sperm at the centre of a target, menaced by bottles of alcohol and chemicals (Merewood, 1991). Another presented a cartoon image of a man and his sperm huddled under an umbrella whilst packets of cigarettes, martini glasses and canisters of toxins rained down upon them (Black and Moore, 1992). Yet of the 853 column inches dedicated to pregnancy, alcohol and drug abuse by the New York Times in one two-year period, almost 200 column inches were taken up by photographic images of crack babies and their drug-addicted mothers (Schroedel and Peretz, 1993). The biological mechanism of paternal–fetal harm have been made invisible not by science itself, but by the lens through which scientiWc evidence is perceived. As Evelyn Fox Keller has observed, un- articulated gender assumptions aVect not only the questions and methodolo- gies of scientiWc research but also ‘what counts as an acceptable answer or a satisfying explanation’ (Keller, 1992: p. For this reason, scientists who have engaged in research on paternal–fetal hazards have met with scepticism from colleagues, editors and newspaper reporters alike. Daniels Paternal effects and ‘political correctness’ Evidence of paternal–fetal harm has generated, at best, virtual silence from public health authorities and the courts, or, at worst, active hostility. An editorial in Reproductive Toxicology (Scialli, 1993) argued that the impulse to link paternal exposures with fetal eVects is a result not of science but of ‘political correctness’, ‘There has been no quarrel that testicular toxicants can produce fertility impairment, but paternally mediated eVects on conceived pregnancies is [sic]adiVerent matter altogether’. The article concedes that ‘several’ studies on paternally mediated eVects have been ‘nicely performed and reported’, but taken as a whole they are ‘diYcult to interpret’ (Scialli, 1993: p. Of those who defend the evidence for paternal/fetal links, the editorial (Scialli, 1993) concludes: The people who make these accusations appear to believe that paternally mediated eVects must occur in humans, for the sake of fairness. It is argued that because father and mother make equal genetic contributions to the conceptus, they must have equal opportunity to transmit toxic eVects. Yet except for those rare and tragic cases where women are exposed to substances such as thalidomide which cause severe, visible deformities, the question of causality remains profoundly complicated for both women and men. The fact that even the chronic abuse of drugs and alcohol by men has been dismissed, whilst so much attention has focused on even the occasional use of drugs and alcohol by pregnant women, points to the clear ways in which gendered constructions shape both the science and policy of risk. Even in cases where men are exposed to known reproductive hazards, scientists have been remarkably reluctant to recommend the most simple restrictions on men. At the Wrst major medical meeting on male-mediated developmental toxins at the University of Pittsburgh in 1992, men were given ‘conXicting advice’ about whether to postpone procreation during cancer treatment (or ‘bank’ sperm before treat- ment).

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Anticholinergic drugs generic flavoxate 200mg with amex spasms to the right of belly button, hyoscine order generic flavoxate on line spasms while pregnant, propantheline order flavoxate 200mg mastercard back spasms 40 weeks pregnant, pirenzepine, amisulpride or clonidine are suggested remedies. Lund ea (2001) found no greater risk of diabetes or hyperlipidaemia than with conventional agents, but Newcomer ea (2002) have shown that clozapine is associated with hyperglycaemia. Clozapine should be withheld for 24 hours after a seizure and restarted at a lower dose. Great care is required in those patients with prostatic enlargement, narrow angle glaucoma or paralytic 3799 ileus. The latter were more likely to have been relatively elderly at the start of therapy with this drug. Despite the number of potentially serious complications, clozapine may reduce the net mortality rate, possibly by reducing the suicide rate. Marder ea, 2003) A single dose of risperidone reduces glucose metabolism in the ventral striatum, thalamus and frontal cortex, and the tachycardia at rest, palpitations, arrhythmias, chest pain, other signs of heart failure, or symptoms suggestive of myocardial infarction. Extrapyramidal signs, seizures, hypersalivation, big pupils, cycloplegia, labile temperature, hypotension, tachycardia, cardiac arrhythmia, and dyspnoea may be found. Management involves gastric lavage with or without activated charcoal if the time since ingestion is less than six hours. Treat symptoms and monitor organ function and electrolyte levels and acid-base balance. Working memory may be improved in risperidone-treated schizophrenic patients compared to those patients receiving haloperidol or, according to Bilder ea,(2002) even clozapine. There is evidence from a double-blind multicentre prospective trial that risperidone is superior to haloperidol in reducing the risk of relapse in clinically stable outpatient schizophrenic and schizoaffective patients. Doses over 5 mgs bid 3802 probably give no increase in efficacy, and the optimal dose may be c 6 mg/day. Transient hypertension could follow abrupt withdrawal of risperidone, possibly due to withdrawal of its alpha-1 blocking effect. Randomised trials in elderly demented patients suggest a threefold increase in cerebrovascular adverse events (3. Patients should be monitored for any evidence of such events and consideration should be given to stopping the drug if necessary. Of note is the finding of a systematic review of risperidone and olanzapine in demented patients (Lee ea, 2004) that found adverse events to be common, i. A SmartSite Vial Access Device offers needle-free access to the vial of microspheres, thus eliminating the original need for 3 needles. It is recommended that the drug be administered orally for three weeks until therapeutic levels of the long-acting drug are achieved, after which attempts are made to withdraw oral risperidone. One naturalistic study of 50 patients found an attrition rate of 42% at six months. According to Turner ea (2004) a stable patient’s conventional depot antipsychotic drug can be changed directly to Risperdal Consta without an intervening period on oral 3805 risperidone. It is suggested that one-third of its effects on negative symptoms is attributable to a direct drug effect. It improves personal and social functioning and may have a relatively early therapeutic effect. It improves depression in 3813 schizophrenia more than does haloperidol , although it was equally efficacious (but 3804 Some authorities give oral risperidone until the patient has received the third Consta injection. They also give oral risperidone for 3 or 4 weeks after an increase in Consta dosage. However, Risperdal Consta has been given to patients with schizophrenia or schizoaffective disorder (diagnosed within previous 3 years, symptomatically stable, on same dose of an antipsychotic for at least 1 month, open and non-comparative study) and was well accepted. Cognitive function may be improved in olanzapine-treated schizophrenic patients, but probably by little more when compared with low doses of haloperidol or with other atypicals. Smoking and carbamazepine induce activity in cytochrome P450 1A2 enzyme, increasing olanzapine metabolism. The starting dose is 10 mg (elderly or in people with hepatic or renal impairment = 2. Eight fatalities were reported as of August 31, 2004 (cardiorespiratory arrest, hypotension, and bradycardia). Olanzapine is ‘contraindicated’ in elderly patients with dementia-related psychosis and/or behavioural disturbance because of evidence for an association with an increased mortality rate and a greater likelihood of stroke. A rough approximation of 3820 dose is got from dividing the dose of injection by the number of days between injections which gives the oral dose/day in mgs.