By R. Aidan. Eastern New Mexico University.

If this occurs activity should be curtailed purchase aspirin 100pills fast delivery, the man sat upright cheap aspirin 100 pills on-line, and if necessary given sublingual nifedipine cheap 100 pills aspirin free shipping. For erection: • Oral sildenafil • Intracavernosal drugs Preparation for sexual intercourse • Vacuum erection aid and compressive retainer ring • Penile implant (small risk of infection or extrusion) Preparation for sexual intercourse includes ensuring that the • Sacral anterior root stimulator bladder is as empty as possible cheap aspirin 100 pills free shipping. A man with an indwelling For ejaculation or seminal emission: catheter should preferably remove it purchase 100pills aspirin free shipping, but it may be strapped • Vibrator back on to the shaft of the penis. The able-bodied partner tends to be the more • Hypogastric plexus stimulator active, and this has a bearing on the positions used for To collect spermatozoa: intercourse. The quality of the (possible in men during ejaculation, and in women during labour, if seminal fluid may improve with repeated ejaculations, however, lesion above T6) and successful insemination has been reported both with the • Sublingual nifedipine or vibrator and by electroejaculation. It is essential to obtain • Glyceryl trinitrate (potentially fatal interaction with sildenafil) microbiological cultures of the seminal fluid and to eradicate 68 Later management and complications—I any infection prior to proceeding with any attempt at Box 13. The success rate has recently improved with the use of assisted conception techniques, including enhancement • If lesion complete above T10, labour may be painless, therefore of seminal fluid, intrauterine insemination, and assisted admit to hospital early, before labour commences reproductive technology, such as in vitro fertilisation (IVF) and • Increased risk of assisted delivery because of paralysis of intracytoplasmic sperm injection (ICSI). Autonomic dysreflexia during labour is a risk in patients with lesions at T6 and above, but this complication can be prevented by epidural anaesthesia. Fulfilment in relationships It should be emphasised that emotional and psychological factors are as important as physical factors in a satisfying relationship and that such a relationship is possible even after severe spinal cord injury. This needs reiterating, particularly to young men who are otherwise apt to see their altered sexual function as a profound loss. Although sensation in the sexual organs may be reduced or absent, imaginative use can be made of touching and caressing, as areas of the body above the level of the spinal cord lesion may develop heightened sensation as erogenous zones. Some couples find that the extra time and effort required for sexual expression after one of them has suffered a spinal cord injury enriches their lives and results in a more understanding and caring relationship. Transrectal electroejaculation combined with in-vitro fertilization: effective treatment of anejaculatory infertility due to spinal cord injury. Human Reproduction 1997;12:2687–92 • Cross LL, Meythaler JM, Tuel SM, Cross AL. Sexual problems associated with spinal and may develop heightened sensation cord disease. Spinal • Extra time and effort required can result in more understanding cord disease—diagnosis and management. New York: Marcel and caring relationship Dekker, 1998, chap 28 69 14 Later management and complications—II David Grundy, Anthony Tromans, John Hobby, Nigel North, Ian Swain Later respiratory management of high tetraplegia Box 14. Modern portable ventilators that use a 12-volt battery can be mounted on a wheelchair, allowing the patient a degree of freedom and independence. Speech is possible with an uncuffed tracheostomy tube around which air can escape to the larynx. In a small number of these patients the anterior horn cells of the phrenic nerve are spared and it may be possible to implant a phrenic nerve stimulator to achieve ventilation. The advantages of electrophrenic respiration are that it is more physiological than positive pressure ventilation and it gives the patient more freedom, the equipment being much lighter than a mechanical ventilator. The long-term ventilator-dependent patient needs • Mechanical “domiciliary” ventilation 24-hour care by a team of carers competent to undertake Advantages of electrophrenic respiration endotracheal suction, but not necessarily including a • More physiological than positive pressure ventilation qualified nurse. It may be further complicated by the enforced period of bed rest during which a state of sensory deprivation ensues. The frustrations associated with the physical Acute stage: limitations of such a severe injury are compounded by the fact • Initial stress reaction that most patients are young and before injury led active lives, • Sensory deprivation often expressing themselves mainly through physical activities. Later stages: The sudden inability to continue in this manner and the need • Anxiety and depression to lead a more ordered life can mean a very difficult and • Post-traumatic stress disorder prolonged period of adjustment. Failure to recognise that this • Cognitive problems process can continue for as long as two or three years may • Detecting psychological problems damage the process of rehabilitation and the patient’s ultimate • Appropriate referral • Family resettlement. The patient needs time to come to terms with his • Psychological support and therapy or her new status and to make decisions about the future without undue pressure. Detection of these psychological problems is vital in order to make appropriate referral. Psychological support and therapy has been shown to be very effective in improving mood and also later adjustment in individuals with spinal cord injury. Other psychological problems that may be present following injury include post-traumatic stress disorder in which an individual continually relives their accident and marked problems with memory, concentration, and problem solving.

After leaving the army he took sur- gical training at the Middlesex Hospital under Gordon-Taylor buy discount aspirin 100 pills line, at the Mayo Clinic purchase aspirin 100 pills without a prescription, and at the Hospital for Sick Children in Toronto order 100 pills aspirin mastercard. He joined the staff of the last institution in 1923 and resigned in 1946 to become chief of staff of the Wellesley Hospital 100pills aspirin with amex, then newly recognized by the University of Toronto as an affiliated teaching institution generic aspirin 100pills mastercard. When he retired from his teaching appointment in 1955 he had attained the rank of Associate Professor of Surgery in the University of Toronto. In common with his colleagues at the Chil- dren’s Hospital, he practiced general surgery but with a strong orthopedic bias, and it was not until his move to the Wellesley Hospital that he con- 223 Who’s Who in Orthopedics surgery and medicine in 1922, and gained his doc- torate of medicine with a thesis of special merit in 1924. He was one of the first four candidates to become master of orthopedic surgery in 1926; gained the fellowship of the Royal College of Surgeons of Edinburgh in 1928; and 20 years later in recognition of clinical and academic achieve- ment was elected Fellow of the Royal College of Surgeons of England ad eundem. The determination to serve crippled children was declared from the beginning: his second house surgeon’s appointment was to the Leasowe Children’s Hospital; at the age of 25 he became assistant consultant to the Royal Liverpool Chil- dren’s Hospital, and shortly afterwards to the Alder Hey Children’s Hospital. He was assistant orthopedic consultant to the David Lewis North- ern Hospital from 1928 to 1933 when he became full consultant orthopedic surgeon to Robert Bryan Leslie McFARLAND Jones’s own hospital, the Royal Southern. When the Lady Chapel of the Liverpool The postgraduate course of orthopedic studies Cathedral was thronged with colleagues, students was modified by insistence on preliminary and nurses, sharing with the bereaved family a general surgical training, greater clinical respon- memorial service as simple yet dignified as he sibility, an introduction to clinical research, the himself would have chosen, the sun gleamed academic discipline of preparation of a thesis, and brightly through the stained glass window dedi- above all by the broadening of teaching to cated to service, at the foot of which rest the ashes embrace that of all his colleagues in Liverpool of Robert Jones. The luster It was to the Liverpool school of orthopedics and distinction he added to this historic school of and the traditions of Hugh Owen Thomas, Robert orthopedics will be treasured with pride and Jones and T. McMurray that McFarland dedi- affection by MChOrth graduates, not only in cated his life. Indeed the inspiration and magnetic Great Britain but in every nation of the British personality of Robert Jones shone through many Commonwealth and other countries throughout of his own qualities. He too showed open honesty with disdain unbounded energy, and devotion to duty such that of pomp and arrogance. His intuitive simplicity in recent years he was worried and anxious lest was a heritage of conservative philosophy broad- the ever-widening field of knowledge in basic sci- ened by awareness of new advance. With kind ences might not be reflected fully; still more was humanity he carried the torch of Robert Jones. One of his A true son of Liverpool, Bryan’s life was spent close colleagues has written: on Merseyside, first at the Wallasey Grammar School and then the medical school of the Uni- The present spirit of friendly cooperation between versity of Liverpool, where he graduated in Liverpool orthopedic surgeons is almost entirely of his 224 Who’s Who in Orthopedics making. He was the prime mover in forming the of the end, during a brief return of consciousness Liverpool Orthopedic Circle in 1944. The informal and and momentary recapture of the old sparkle, he frank discussion of cases which follows each monthly instructed his son how to secure and pack dinner of the circle has proved invaluable to its a Scotch salmon to fly back to his chief in members, not only in their work but in forming the America with whom he was working on a surgi- foundations of much closer personal friendships than cal fellowship. McFarland’s con- tributions to the discussions were typical of him, direct This tenacity and indomitable courage was and often pungent, and scorning all pretence and epitomized in his presidential address to the humbug. With McFarland at the head, the postgraduate Philomathic Society on “The Will to Live,” when school flourished. At long illness, beginning while lecturing to old stu- an early meeting, after two issues of the first dents in Australia, and ending so wearily that he British volume had been expensively published, was diffident in welcoming visitors lest he might we reviewed the balance sheet with dismayed not still seem steel blue and blade straight. With anxiety, and the board was informed that after gentle love, and no less firm endurance, he was months of endeavor, post-war controls had not yet sustained and comforted by his wife Ethel. He left been surmounted and there was no Board of Trade behind his wife and two sons John and Andrew. With a Bryan’s concluding words in his Philomathic chuckle McFarland said “ it seems to me that in address were: pursuing an illegal venture we face financial ruin—but we will go on. This feeling, the many councils and associations of which if unhindered by anxious thought, will grow in he became president, including the Liverpool strength; and when the troubled times are over we shall Medical Institution, University Club, Merseyside be just that little bit more balanced in judgment, that branch of the British Medical Association and little bit more determined in character, and that little bit Liverpool Philomathic Society. Of these little bits is built up our the Robert Jones Dining Club, which meets each national character which renders unconquerable our year after the eponymous lecture at the Royal land and invincible our soul. College of Surgeons of England—an oration that he himself gave brilliantly, as he did also the first McMurray Memorial Lecture in Liverpool. He prepared assiduously, for example taking coach- ing lessons in French to improve his continental duties, culminating in the presidency of the Société Internationale de Chirurgie Orthopédique et de Traumatologie. We chaffed him that his French was spoken with a strong Liverpool accent; but we loved him the more. He would leave home at three o’clock in the morning to arrive in Anglesey before dawn for wild-fowl shooting, and a superb shot he was. It was not until after the age of 40 that he became an enthusiastic fish- erman, but so thorough was the preparation and practice that he could equal the skill of any High- land ghillie at Cape Wrath. Within a day or two 225 Who’s Who in Orthopedics suade the giants of industry and commerce to con- tribute to the rebuilding and upkeep of the College.

Two years later the eminent epidemiologist Archie Cochrane caused a furore when he claimed that there was no evidence that smears would reduce the death rate from cervical cancer buy aspirin 100 pills line. He particularly objected to the use of a screening test for a condition for which there was no effective treatment (an authoritative review in 1999 conceded that there had been ‘no significant improvements in treatment for cervical cancer over the past 20 years’) (Quinn et al buy discount aspirin 100 pills. Reflecting some years later on the ‘uproar order aspirin 100 pills with amex, abuse and isolation’ he experienced as a result of his questioning of the cervical smear programme generic aspirin 100pills line, Cochrane commented that cheap aspirin 100 pills visa, because of the introduction of this programme without proper evaluation, ‘we would never know whether smears were effective or not’ (Cochrane 1976:260). In 1988, following criticisms of the haphazard character of the cervical smear system, a National Coordinating Network for the NHS Cervical Screening Programme was established. In 1990 the new contract imposed on GPs by the government offered substantial incentives, now worth around £65 million a year, tied to smear rate performance targets. As a result of these measures, coverage of the target age group rose from 42 per cent in 1988 to 85 per cent in 1994, a level subsequently maintained (Quinn et al. The claim by these authors that in women under 55 ‘screening may have prevented 800 deaths in 1997’ was contested by critics who noted that the data presented could equally well support the conclusion that screening caused a similar increase in mortality (Vaidya, Baum 1999). The contrast between the high level of public faith in the 57 SCREENING cervical smear programme and the private recognition among medical authorities of its unsatisfactory character is remarkable. In their reply to Vaidya and Baum, Quinn and his colleagues admitted that they remained ‘deeply concerned about the well known problems with cervical screening’, which they listed: cervical cancer is a comparatively rare disease and its natural course is not well understood; the smear test has both low sensitivity and low specificity; many tests are techni-cally unsatisfactory and the proportion of such tests varies across the country; the mix of three-year and five- year screening intervals is inequitable; too many smear tests are opportunistic; and the programme costs four times as much as breast screening. The fact that some such cases have resulted in litigation has led to calls for doctors to make clear that smears may miss between 5 and 15 per cent of abnormalities and to ensure that patients are giving properly informed consent to this procedure (Anderson 1999; Nottingham 1999). The low specificity of the smear test means that it yields a relatively high proportion of false positive results: that is, it suggests that a woman has malignant or pre-malignant cells when more invasive procedures (involving the removal of a wider area of tissue in a ‘loop’ or ‘cone’ biopsy) confirm that this is not the case. In day to day practice, this is by far the biggest problem arising from smear tests, causing enormous anxiety and distress, often continuing for weeks or months pending delays in further investigations. Bristol public health consultant Angela Raffle noted the tendency of staff, in response to publicity over missed cases, to over-diagnose minor abnormalities (Raffle et al. While patients suffered needless anxiety, staff lived in fear of failing to identify potentially malignant cases. As a result, ‘much of our effort in Bristol is devoted to limiting the harm done to healthy women and to protecting our staff from litigation as cases of serious disease continue to occur’. As Raffle recognised, many healthy women are left with worries about cancer and difficulties in obtaining life insurance. Those who receive treatment may experience considerable discomfort, bleeding and sexual 58 SCREENING problems—as well as long-term anxieties about fertility. Meanwhile women in that 10 to 15 per cent of the female population which has never had a smear, who are likely to be (like my two patients), older, poorer and from ethnic minorities, will ensure that the mortality figures remain fairly steady. Health promotion propaganda which characterises cervical cancer as a sexually transmitted disease (on the dubious grounds of an association with the wart virus) has undoubtedly deterred many women from having smear tests. The annual cost of the cervical cancer screening programme is £132 million (Quinn et al. This is about four times the cost of the breast screening programme—though the death rate from breast cancer is around ten times greater. Mammography Breast cancer is not only much more common than cancer of the cervix, but the number of cases has gradually increased over the past twenty years. After rising slowly through the 1970s and 1980s, the death rate declined in the 1990s. There are currently around 30,000 cases a year, accounting for one-third of cancer in women; breast cancer kills around 11,000 women every year, causing around one- fifth of female cancer deaths. In our surgery we see several new cases of breast cancer every year and one or two deaths. We see many more women who turn out not have breast cancer but are understandably terrified by the appearance of a lump or other breast symptoms. Trials of mammography—X-ray examination of the breast— for early detection of malignancy were carried out in the USA in the 1960s. Early results showed a resulting reduction in mortality among women over the age of fifty, but no benefit in younger women (Wells 1998). More extensive research in the 1970s confirmed the earlier results and mammography became established as a screening test for breast cancer. In Britain a national screening programme became operational in 1988; now women between the ages of 50 and 64 are invited for free mammography every three years. The combination of mammography with ultrasound and the microscopic study of cells extracted from a suspicious lump through ‘fine needle aspiration’ has greatly improved the diagnostic sensitivity of this process in the 1990s. In response, Professor Michael Baum, who had helped to set up the screening service, pointed out that though the mammography programme could not be expected to have an effect on mortality before 1997, the decline in the death rate began in 1985.

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