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Side effects include painful erection (>17% of males) 25 mg baclofen mastercard, headache baclofen 10 mg lowest price, dizziness generic baclofen 25mg line, flushing generic baclofen 10 mg mastercard, sweating, dyspepsia, nasal congestion, and a bluish tinge to vision (limited inhibition of phosphodiesterase type 6 in the retina), increased light perception or blurred vision. Failure of sildenafil may lead to distress and exacerbation 2106 of low self esteem. Sildenafil citrate (Viagra) 2107 Effective across full range of aetiologies (incl. If nerves are not spared) 2108 Some cases have genetic disorders of retinal phosphodiesterase. Peyronie’s disease: penile curvature due to plaque or scar; painful erection/difficult penetration; may improve spontaneously; advise continued sexual activity; delay surgery until condition stable. A post-mortem erection in men who are hung is technically a priapism and may be due to pressure on the cerebellum. Cimetidine increases sildenafil concentrations, erythromycin even more so; ketoconazole also inhibits enzyme; if necessary use low dose of sildenafil, e. It is contraindicated with organic nitrates or in the presence of significant cardio- or cerebro-vascular disease. Possible side effects include headache, dizziness, dyspepsia, flushing, nasal congestion, back/muscle pain, eyelid swelling, eye pain, and hyperaemic conjunctivae. Avoid vardenafil with nitrates/nitric oxide donors, contraindications to sexual activity (e. Avoid vardenafil in patients with anatomical abnormalities or a proneness to priapism. Downward dose adjustment (5 mg) may be needed if vardenafil is co-prescribed with erythromycin. Risk- benefit analysis must be undertaken for cases with bleeding diatheses or active peptic ulcer disease. Adverse effects include dyspepsia, nausea, dizziness, syncope, headache, rhinitis, flushing, hypertension/hypotension, hypotonia, visual 2116 disturbance , photosensitivity reactions, and erectile disturbance. When prostaglandins (embryotoxic in animals) are used by the male and the female partner is pregnant it is advised that the foetus is protected by barrier contraception (e. Intracavernosal prostaglandin E1 (Alprostadil, Viridal - metabolised locally) gives a good erection (both it and papaverine produce erections lasting 30-60 mins). Self-injection of papavarine, phenoxybenzamine or phentolamine into the cavernosa at the penile base gives a normal erection, which lasts about forty minutes. Papaverine injections have been used to differentiate between neurological and vascular causes. In males with an intact genital circulation, injections into the corpora cavernosa of either beta-blockers (phenoxybenzamine or phentolamine) or other smooth muscle relaxants (e. Potentially serious side effects include priapism (admit immediately, aspirate the corpus cavernosum and inject phenylephrine 5 mgs. Post-radical prostatectomy) may respond to alprostadil injected into corpora cavernosa (Caverject, Viridal Duo). Stick strength range from 125 to 1000 mcgs and the correct dose should be worked out under medical supervision. The only sexual dysfunction that can be (almost) cured completely is vaginismus: we are dealing with methods to alleviate the problem or to achieve better control. Departments of psychiatry, focused on serious mental illness as they are, rarely work with sexual problems, and special clinics are uncommon. According to some experts, up to 70% of venous leakage cases, where blood drains away from the penis too quickly, can expect improvement with surgery. However, other experts consider the results of this type of operation, and of revascularization of the corpora, to be poor. Priapism is the persistent, prolonged, uncontrolled and usually painful penile erection. Removal of a physical cause does not invariably remove the dysfunction because of conditioned anxiety (which may require couple therapy). Anodyspareunia is pain from receptive anal sex and is common in gay men and may be persistent. It may lead to avoidance of anal sex or to the sole practice of insertive anal sex. It can be associated with impotence or passivity in the partner (which may become obvious after treating the woman). Causes include arthritic conditions, vaginal surgery/tumour/trauma/atrophy, uterine prolapse, endometriosis, congenital problems, hymenal problems, pelvic congestion, and sexually transmitted infection. Orgasmic dysfunction is an inability to attain orgasm (anorgasmia) or an undue delay in attaining orgasm. As in male impotence, orgasmic dysfunction may be primary (never attained) or secondary (ability lost). About 20% never or hardly ever achieve unassisted orgasm during sexual intercourse; 30% almost always achieve 2122 Implants/prostheses are used less often nowadays than they were in the past. Studies of pudendal nerve conduction and evoked potentials can be performed if indicated. Treatment is aimed at education, reduction of fear, and enhancement of sexual arousal. Antidepressant-induced anorgasmia may respond to cyproheptadine 2-16 mgs before sexual activity. Cyproheptadine is a serotonin antagonist and may sometimes cause a relapse of depression in individuals prone to develop it. There is no evidence to suggest that women possess a ‘G spot’ 2126 (Grafenberg spot) in the anterior vagina. They progress through mutual fondling (active and passive), eventually caressing breasts and genitalia (so-called sensate focus). This is all accompanied by therapeutic evaluation and attempts to improve general relationship problems. The initial ban on intercourse, the aim being to reduce performance anxiety, was first suggested by John Hunter in the 18th century. Some unusual conditions Pseudocyesis (phantom pregnancy), which is also found in other mammals, is basically a form of conversion hysteria with lordosis of the lumber spine, depression of the diaphragm, and possibly aerophagy (air- swallowing). The frequency of the condition is not known for sure (1 in 2129 200/250 maternity clinic admissions). Psychological explanations include an extreme desire to conceive or fear or guilt surrounding pregnancy. Simulated pregnancy: A woman declares herself to be pregnant when she knows she is not. Delusional pregnancy: A woman (or man) believes she is pregnant (even with the Messiah! It has followed loss of a baby and rejection by the spouse in a schizophrenic Indian woman. It is not delusional, although delusions of male pregnancy may occur, as in schizophrenia. Spontaneous miscarriage/abortion 25% of women have a miscarriage at some stage of their lives.

Accessibility of addiction treatment: Results from a national survey of outpatient substance abuse treatment organizations generic baclofen 10mg without prescription. Screening and intervention for illicit drug abuse: A national survey of primary care physicians and psychiatrists order baclofen 25mg. Screening and intervention for alcohol problems: A national survey of primary care physicians and psychiatrists buy baclofen 25mg without a prescription. Management of adults recovering from alcohol or other drug problems: Relapse prevention in primary care baclofen 10mg for sale. Use of integrated dual disorder treatment via assertive community treatment versus clinical case management for persons with co-occurring disorders and antisocial personality disorder. Managing asthma: An evidence-based approach to optimizing inhaled corticosteroid treatment. Relationship of work-family conflict to substance use among employed mothers: The role of negative affect. Relationship of work-family conflict, gender, and alcohol expectancies to alcohol use/abuse. Are physicians and medical students prepared to educate patients about alcohol consumption? Racial/ethnic disparities in the use of nicotine replacement therapy and quit ratios in lifetime smokers ages 25 to 44 years. Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system. Office- based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. Access to resources for substance users in Harlem, New York City: Service provider and client perspectives. Mental health quality and accountability: The role of evidence-based practices and performance measures. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: A randomized controlled trial. Diagnostic profiles associated with use of mental health and substance abuse services among high-risk youths. Research on the diffusion of evidence-based treatments within substance abuse treatment: A systematic review. Confronting the obstacles to screening and interventions for alcohol problems in trauma centers. A physician believes widespread substance use screening in primary care will boost specialty treatment. Effect of the Uniform Accident and Sickness Policy Provision Law on alcohol screening and intervention in trauma centers. Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Alcohol screening and intervention in trauma centers: Confidentiality concerns and legal considerations. Safety and efficiency of an anti-(+)-methamphetamine monoclonal antibody in the protection against cardiovascular and central nervous system effects of (+)-methamphetamine in rats. Help-seeking for alcohol-related problems: Social contexts surrounding entry into alcoholism treatment or Alcoholics Anonymous. Individual differences in prefrontal cortex function and the transition from drug use to drug dependence. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. The effects of negative life events on alcohol consumption among older men and women. Journals of Gerontology: Series B: Psychological Science and Social Science, 50(4), S205-S216. Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders. Social networks and methadone treatment outcome: The costs and benefits of social ties. Opiate withdrawal using clonidine: A safe, effective, and rapid nonopiate treatment. Designing a smoking cessation intervention for the unique needs of homeless persons: A community-based randomized clinical trial. Effects of behavioral skills training and schedule of nicotine gum administration on smoking cessation. Dysfunction of the prefrontal cortex in addiction: Neuroimaging findings and clinical implications. Cigarette smoking and panic attacks among young adults in the community: The role of parental smoking and anxiety disorders. The accuracy of self-reported smoking: A systematic review of the relationship between self-reported and cotinine- assessed smoking status. Provider, patient, and family perspectives of adolescent alcohol use and treatment in rural settings. A pilot study comparing motivational interviewing and an educational intervention in patients with schizophrenia and alcohol use disorders. Neuropsychological functioning and outcomes of treatment for co-occurring depression and substance use disorders. Barriers to alcoholism treatment: Reasons for not seeking treatment in a general population sample. Adolescent alcohol use is a risk factor for adult alcohol and drug dependence: Evidence from a twin design. Nutrition education is positively associated with substance abuse treatment program outcomes. Services for perinatal women with substance abuse and mental health disorders: The unmet need. Substance abuse treatment for women: Changes in the settings where women received treatment and types of services provided, 1987-1998. Drug treatment outcomes for adolescents with comcorbid mental and substance use disorders. Perceptions of need and help received for substance dependence in a national probability survey. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Outcomes of implementing patient centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence.

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The patient should remove all clothing and jewelry above the waist and wear a hospital gown open in the front effective baclofen 10mg. History should include date of any breast injury cheap baclofen 10mg otc, biopsy or surgery generic baclofen 25mg with visa, hormone therapy cheap baclofen 10mg without prescription, chemotherapy, or radiation therapy. Scintigraphy should be delayed two weeks following cyst or fine needle aspiration, and four to six weeks following a core or excisional biopsy. Inject the arm contralateral to the breast with the suspected lesion; in patients with bilateral lesions or post-mastectomy patients, inject a foot vein. The patient lies prone with a single breast freely dependent from the imaging table. The contralateral breast should be compressed against the table to prevent cross-talk of activity. The patient’s sternum lies on edge of table or use table overlay with cutout for breast. Begin imaging 10 minutes post-injection; delayed images are generally unnecessary. Prone 30 posterior oblique view of the ipsilateral breast to throw lesion near the chest wall more anteriorly. Prone lateral view of the contralateral breast (oblique unnecessary unless bilateral lesions). Anterior upright (or supine) chest image to include both axillae with both arms raised. If the lesion is medial in location, a supine medial oblique view may be obtained by rotating the patient to the side and supporting her with a foam wedge allowing gravity to pull the breast away from the chest wall but not allowing a mobile breast to wrap around the lateral chest wall. Make sure the opposite breast is held away from the medial chest wall until the camera can be brought down to hold it out of the way. Place the camera parallel to the patient with an additional angle of 1-2 degrees away from the patient to separate the breast from the chest wall. If a radioactive marker is desired over a palpable abnormality, the marker must be placed after the patient is placed in the prone position. Masking of the high-activity chest and abdominal organs such as the myocardium and liver from the final images will improve visualization of breast tissue. Tchnetium-99m-sestamibi scintimammography of breast lesion: clinical and pathological follow-up. Revised 1/3/2007 Breast Lymphoscintigraphy for Augmentation Mammoplasty Protocol Purpose: To determine whether augmentation mammoplasty alters lymphatic drainage of the breast. Each patient will have lymphoscintigraphy performed pre-operatively and again post- operatively 12 weeks after mammoplasty. Time interval between administration and imaging: immediate Patient Preparation: 1. Photopeak and window settings predetermined for Tc (140 keV, 20%) Procedure: 99m Injection: 1 mCi of filtered Tc sulfur colloid in 2. Frequent 5-minute static images are acquired for one hour in the anterior projection with the ipsilateral arm held above the head; additional anterior images should be acquired with the ipsilateral torso supported by a wedge into an obliqued position 2. Use Cobalt markers, transmission imaging, and outlining of the body contour with a 99m Tc source as necessary Processing: 1. Physiologic activity is seen in the normal prostate gland, liver, spleen, bone marrow, blood pool, genitalia, bladder, kidneys and frequently the bowel. Capromab activity is common at inflammatory sites, including Lupron injection sites, pneumonitis, hernia, tendinitis, arthritis, incision sites (for mos-yrs), Paget’s disease, spermatic cord sites, colostomy sites, aneurysms, and radiation enteritis (for yrs). Anaphylaxis precautions as per all antibody injections: acute hypotension has been reported; patients with a history of drug reactions or allergies should be observed for 2 hrs p. At 96 hours perform dual isotope whole body imaging in the anterior and posterior projections from skull through mid-femur; change colostomy bag before imaging 3. If patient must return for 120 hr acquisition, should eat high fiber diet and use 111 laxative that evening. Use planar images to evaluate extent and distribution of stool and blood pool, to detect disease outside the pelvis (central abdominal and supraclavicular nodes) and to look for altered biodistribution 2. Multicenter radioimmunoscintigraphic evaluation of patients with prostate carcinoma using indium-111 capromab pendetide. Comparison of clinical staging algorithms and 111indium-capromab pendetide immunoscintigraphy in the prediction of lymph node involvement in high risk prostate carcinoma patients. Immunoscintigraphy with indium-111-capromab pendetide: evaluation before definitive therapy in patients with prostate cancer. The dual-isotope ProstaScint imaging procedure: clinical experience and staging results in 145 patients. Response rates have varied from 50-90% with duration of responses of one to five years. The major restriction requires that the total effective dose equivalent to any other individual from exposure to the released patient is < 500 mrem. Using these assessments, patients who do not meet releasability criteria or who cannot comply with detailed instructions would not be considered releasable. Since the radiopharmaceutical is administered intravenously, there is rapid total body distribution; significant enteric contamination is very unlikely. I-131 anti-B1 antibody is excreted renally, so the primary source of any contamination would be the bathroom. If good hygiene is adhered to by the patient and family members, exposure due to internal contamination should be minimal, with the caveat that small children should use a separate bathroom. After consultation with the referring physician, nuclear medicine staff, and the Vanderbilt University Radiation Safety Officer, a decision regarding releasability will be determined for each patient prior to therapy. With adherence to the above guidelines we can expect that released patients will expose other adult, non-pregnant individuals to a total effective dose equivalent of no more than 500 mrem and children or pregnant women to less than 100 mrem. The advantages of outpatient management of these patients include (1) shorter hospital stays accompanied by lower health care costs, (2) psychological and emotional benefits to patients and family members, (3) lower exposure to hospital staff and (4) heightened opportunities for this and other medical centers to participate in funded clinical research protocols. Patient-Specific Whole-Body Dosimetry: Principles and a Simplified Method for Clinical Implementation. Iodine-131 Anti-B1 Antibody for B-Cell Lymphoma: An Update on the Michigan Phase I Experience. Revised Nuclear Regulatory Commission Regulations for Release of Patients Administered Radioactive Materials: Outpatient Iodine-131 Anti-B1 Therapy. The technologist who initiates the procedure on the day of therapy when the dose is ordered should also administer the dose after personally confirming the dose at the time of administration with the attending physician or physician-in-training who ordered the dose. A copy of the prescription should be available at the time the dose is administered, and the dose should coincide (+/- 10%) with the prescribed dose. A signed prescription should be provided to the radiopharmacist before the dose is ordered and should be faxed to the vendor in addition to the paperwork already required by the vendor. Any and all student participation in therapeutic administrations must be very closely monitored. Diagnostic Dose 2 (1) Prepare unlabeled anti-B1 antibody rituximab (Rituxan), 250 mg/m 111 (2) Obtain In-ibritumomab tiuxetan, 5 mCi (3) Administer acetaminophen 650 mg po and diphenhydramine 50 mg po (or chlorpheniramine 4 mg po) 30-60 minutes prior to initiation of Rituxan infusion. Fatal infusion reactions have occurred with Rituxan; see package insert regarding infusion instructions. Whole Body Imaging Camera: dual-head Collimator: medium energy 111 Window: dual window for In (171 keV and 245 keV with 20% window) Matrix: 256 x 1024 nd rd Scanning speed: 10 cm/min for first scan; 7 cm/min for 2 scan; 5 cm/min for 3 scan.

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The sentinel node is defined as the first node in the lymphatic basin that drains to the primary tumor; it is not necessarily the node closest to the primary tumor baclofen 25mg free shipping. The surgeon needs a map of the position of the sentinel node in reference to the other nodes in the basin in order to do sentinel node harvesting under local anesthesia with a small incision cheap 25mg baclofen with amex. Scintigraphy in 2 planes with cutaneous marking of the sentinel node and any in transit nodes is necessary buy baclofen 25 mg overnight delivery. In transit nodes are defined as tracer accumulation in the subcutaneous tissue between the primary site and the regional nodal basin order baclofen 10mg. Delayed imaging is necessary to ensure that all basins with lymphatic drainage are visualized. Intraoperatively, an in vivo "hotspot" to background activity ratio of at least 3:1 or an ex vivo sentinel node to nonsentinel node ratio of at least 10:1 is minimal acceptable criteria for sentinel lymph node identification. Obtain from radiopharmacy 450 microCi filtered Tc sulfur colloid in 6 ml saline divided into six 1 ml syringes. Two to six hours pre-operatively, the radiopharmaceutical will be injected subcutaneously around the breast tumor in a circumferential manner by a physician. Route: Directly placed into eye via pipette or syringe (near the lateral canthus). Instill the conjunctival sac laterally of both eyes simultaneously and begin imaging immediately. The radionuclide sialogram permits direct visualization of parenchymal glandular tissue. Various functional aspects of the salivary gland including blood flow, trapping mechanism of ductal epithelium, and patency of ductal pathways can be evaluated noninvasively by scintigraphy. The procedure is a sensitive, physiologic approach which frequently discloses salivary gland abnormalities of systemic diseases prior to development of morphologic changes and clinical manifestations. Radionuclide sialography, however, suffers a serious drawback in its inability to detect nonpalpable masses or those smaller than 2 cm in size and to differentiate intrinsic from extrinsic lesions. Demonstration of the normally functioning gland and its rapid response to lemon juice is reassuring as to the psychosomatic nature of the problem. Its association with rheumatoid arthritis, as well as with other connective tissue and collagen vascular diseases such as systemic lupus, scleroderma, and polymyositis is well known. Evaluation of Sialolithiasis Prior to Surgery Complete long-standing ductal obstruction due to sialolithiasis results in parenchymal atrophy and a nonfunctioning gland (cold gland). Evaluation of Focal Glandular Enlargement When a focal mass is present within the gland, its functional status must be determined. Primary tumors of salivary glands are rare and the majority of these are benign (85%). The most common type of benign tumor is the pleomorphic adenoma (mixed tumor) which comprises approximately 75% of salivary tumors. These are commonly seen in females during the 4th and 5th decades of life; these tumors are usually "cold", but it is not uncommon to see mixed tumor as a functional mass. The tumor is soft and predominantly cystic, is located immediately beneath or outside the parotid gland capsule, and is invariably "hot" by radionuclide sialography. Less than 1% of benign salivary gland tumors are oncocytoma and these tumors can be "hot" or "cold". Time interval between administration and scanning: Immediate Patient Preparation: Check that the patient is not pregnant or breast feeding. Inject the radiopharmaceutical as a bolus with saline flush using a 3-way stopcock. Make a concerted effort to precisely locate all abnormal foci using cobalt markers and additional views. The patient should be on clear liquids only for 4 hours prior to radioiodine administration. Acquire anterior and posterior images of the whole body (including the distal extremities for neuroblastoma patients). Make a concerted effort to precisely locate all abnormal foci using cobalt markers and additional views. Image the standard 2 cm from collimator in anterior and posterior projections at each whole body acquisition; use identical separation distance of heads. Must stop scan at overflow when scanning the std and the patient and document the duration of the scan. Calculate the % uptake for each lesion: uptake = (lesion cps x F) / std cps F = fraction of administered activity in the standard. Visualization of somatostatin-receptor rich tumors such as islet cell tumors, medullary carcinomas of the thyroid, pheochromocytomas, neuroblastomas, pituitary adenomas, carcinoid tumors, and other neuroendocrine tumors is achieved with a sensitivity of 80-90%. Physiologic activity is seen in the normal pituitary gland, thyroid gland, liver, bladder, and frequently the bowel. Time interval between dose administration and scanning: 4 hours, 24 hours, and occasionally 48 hours. Concurrent administration of Somatostatin receptor agonist (Sandostatin) therapy is not a contraindication to octreotide scintigraphy and does not diminish sensitivity for detection of neoplasm. At 4 hours perform whole body imaging in the anterior and posterior projections from neck down to and including the pelvis, using step and shoot procedure at 5 minutes per step. At 24 hours, perform whole body imaging in the anterior and posterior projections from the head to the distal femurs using 10 minutes per step. With filter attached to 10 cc syringe, withdraw entire contents of antibody vial 9. Views acquired for 10 minutes: Anterior and posterior chest, abdomen, and pelvis 3. When filming, adjust threshold to see vascular structures (liver will be intense). Have patient void immediately before imaging 3 Change colostomy bags before imaging 4. The sensitivity in most reported series is in excess of 90% for palpable lesions but is no higher than 50% for nonpalpable lesions. Specificity ranges from 70-87% with false positive accumulation seen at the areolae (in 3-5% of women) and in sclerosing adenosis, fibroadenoma, new/chronic infections, and in the region of any recent biopsy. Identification of multicentric carcinoma in patients with tissue diagnosis of breast cancer. Patients must be able to lie prone with arms raised for planar imaging, 20-40 minutes. The patient should remove all clothing and jewelry above the waist and wear a hospital gown open in the front. History should include date of any breast injury, biopsy or surgery, hormone therapy, chemotherapy, or radiation therapy. Scintigraphy should be delayed two weeks following cyst or fine needle aspiration, and four to six weeks following a core or excisional biopsy. Inject the arm contralateral to the breast with the suspected lesion; in patients with bilateral lesions or post-mastectomy patients, inject a foot vein. The patient lies prone with a single breast freely dependent from the imaging table. The contralateral breast should be compressed against the table to prevent cross-talk of activity.

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Captain Bob Hoke generic baclofen 25mg visa, “Health and Healthing: Beyond Disease and Dys­ functional Environments order 25 mg baclofen with visa,” paper presented at the Annual Meeting of the American Association for the Advancement of Science order baclofen 10 mg with amex, Washing­ ton discount 10 mg baclofen with mastercard, D. See also his “Man-Environment Rela­ tions and Healing,” paper prepared for the American Psychiatric Association Annual Meeting, Honolulu, Hawaii, 1973. Captain Bob Hoke, “Promotive Medicine and the Phenomenon of Health,” Archives of Environmental Health, 16, 269-278. Marc LaLonde, Minister of National Health and Welfare, A New Per­ spective on the Health of Canadians (Ottawa: Government of Canada, 1974), pp. See Disease, Life and Man, Selected Essays by Rudolf Virchow, Helfand Rather (trans. Garrett Hardin, “The Tragedy of the Commons,” Science, 162 (De­ cember 13, 1968), 1243-1248. The fact that providers of medical care do stimulate a demand for their services is incontrovertible. Departm ent of Health, Education, and Welfare, "Determinants of Expenditure for Physicians’ Services in the U. Bunker, “Surgical Manpower,” Neu’ England Journal of Medicine, 282, 3 (January 15, 1970). There are some doubters; among them is Harry Schwartz, who argues that the worst of the cost crunch is over. See Harry Schwartz, The Case for American Medicine: A Realistic Look at Our Health Care System (New York: David McKay Co. This analysis does not take into consideration earlier "medicines,” such as Greek or Roman medicine. Lord Ritchie-Calder, Medicine and Man (New York: Signet Science Library, 1958), p. See John Powles, “On the Limitations of Modern Medicine,” Science, Medicine and Man, 1 (1973), 13. See Max von Pettenkofer, “The Value of Health to a City,” lectures quoted in Bulletin of the History of Medicine, 10 (1941), 487-503. Cochrane, Effectiveness and Efficiency (London: The Nuffield Provincial Hospitals Trust, 1972). Authoritative commentators like Jerom e Frank are beginning to assess its importance. Abraham Flexner, Medical Education in the United States and Canada (New York: Carnegie Foundation for the Advancement of Teaching, 1910). Crombie, “The Future of Biology, the History of a Program,” Federal Procedure, 25 (1966), 1448-1453. Leo Tolstoy, “The Death of Ivan Illyich," in Leo Tolstoi, Short Stories, Margaret Wettlin (trans. Barbara Ehrenreich and John Ehrenreich, The American Health Empire: Power, Profits and Politics (New York: Random House, 1970). Rashi Fein, “On Achieving Access and Equity in Health Care,” Milbank Memorial Fund (hiarterly, 50, 4 (October, 1972), 158-159. Jerome Schwartz, “A Critical Review and Evaluation of Smoking Con­ trol Methods," Public Health Report, 84, 6 (June 1969). The research was reviewed in The Los Angeles Times, November 14, 1973 (emphasis added). Some earlier findings can be found in Lester Breslow and Bonnie Klein, “Health and Race in California,” American Journal of Public Health, 61, 4 (April 1971). Although I do not entirely relish the association, the best piece on this subject I have read is a chapter by Milton Friedman in his book, Capitalism and Freedom (Chicago: University of Chicago Press, 1962). John Radar Platt, “Hierarchical Restructuring,” Bulletin of Atomic Scien­ tists, November 1970. Peter Sedgewick, “Illness—Mental and Otherwise," Hastings Center Studies, 3 (1973), 37. As Chapter 2 indicates, the technology of outcomes assessment must be rapidly improved if this is to be accomplished. For a fascinating article on the relationship between disease and old age, see Alexander Leaf, M. Ailment Receives Little Attention, Doc­ tor Says,” The Los Angeles Times, November 6, 1972. The Ambulance Scandal: A Hazard to Life and Health,” Medical World News, 11 (December 4, 1970). Doxiadis, Constantine, “Confessions of a Criminal,” Los Angeles Times, January 7, 1973. Transcript of the Interdisciplinary Symposium of the American Academy of Parapsy­ chology and Medicine, San Francisco, October 30, 1971. The Changing Age Profile, Implications for Policy Planning in Metropolitan Washington. Edward, 22 Amphetamines, 15-16, 97-98 Bernard, Claude, 207 Ancient cultures, 146,199-201 Biofeedback, 67-68, 152 Anderson, Odin W. See also Stress Cancer, 73-74, 89,91,96 Congress, 2—3, 74—75, 96, 228 causes, 103-106, 109-110 Consumers Union, 98 incidence, by type and by country, Cooper, Brian, 111 49-50, 76,103-104 Coronary Care Units, 124-128 racial comparisons, 109 Counter culture, 148-149 treatment, 69 Crick, Frances, 62 Caring, 19-20 Crombie, A. See also Mortality Cartesian tradition, 34, 201 DeBakey, Michael, 265 Cassel, John, 25, 87 de Brigard, Raul, 120 Castaneda, Carlos, 147, 159-160 Delivery system development, 51-53, Cayce, Edgar, 146 130-132, 209-210, 228 Center for the Study of Responsive Department of Health, Education and Law, 9 Welfare, 135 Chase, Allen, 21 DeRopp, Robert S. Geller, Uri, 164-166 S e e a ls o Poverty Genetics, 104-105,113,119, 121, 123 Eddington, Sir Arthur, 165 Geographic factors in disease, 5 0 -5 1 , Education, 2 -3 , 175 55-5 6 effect on health, 2 5 -26, 53 Gerger, Alexander, 218-219 s e e a ls o Health education Geriatrics, 82. Edward, 227, 229 Hodgkins disease, 12 Kenniston, Kenneth, 148 Hoke, Bob, 189-190 Kessner, David, 11 Holistic medicine, 34, 36, 210 Kidney dialysis, 124-128 Hollingshead, A. See also Poverty Technology Malpractice, medical, 16 see also Drugs; Medical care Marches, J. Ross, 255 to ,28,138-139,256 McHale, John, 263 Mercury, ingestion of, 109 McKean, Joseph, Jr. See also Psychic Mosteller, Frederick, 241 phenomena and Psychic healing Muller, Charlotte, 14 Parapsychology, 163 Multinational corporations, 246 Parsons, Talcott, 180 effect on, world health organizations, Pasamanick, Benjamin, 255 48, 138 Pasteur, Louis, 179, 203-204 disease transmission, 49 Patients, ability to pay, 39-40 Mumford, Lewis, 145 access to care, 39-40,134-135, Mutagenicity, 104-105 137 Myrdal, Gunnar, 53 attitudes, 44 dependency, 37, 45, 71-72 Naranjo, Claudio, 260 see also Physician-Patient relation­ National Bureau of Economic Re­ ship; Self care search, 25 Pearl, Arthur, 257 National Center for Health Statistics, Pediatrics, 82 241 Pekkanen,John,15 National health insurance, 2 -5 , 47, 51, Penis, toad tied to, 117 130, 134, 194, 227-230 Pesticides, 106-107, 151 British National Health Service, 2 2 - Pettenkofer, Max, 106 23, 47,51,61,218, 246 Pharmaceutical industry, 15 National Institute of Alcohol Abuse Physician-patient relationship, 34-35 and Alcoholism, 91 3 7 ,4 3 -4 5 ,7 1 -7 2 , 124, 132- National Institute of Cancer, 77 133 National Institute of Environmental Physicians, distribution of, 39-42 Health Sciences, 105 family practitioners, 40 National Institutes of Health and general practitioners, 41 Mental Health, 74, 89, 120 geriatricians, 82 National Research Council, 94 influence on system, 43,132,139, Neely, Sen. Abraham, 227 Poverty, 118,136-139, 175 Ridken, Ronald, 110 Powell, Enoch, 229 Riessman, Frank, 257 Powles, John, 24, 213-214 Risley, Mary, 245 Pregnancy,45 Roemer, Milton I. Salk, Jonas, 143-144, 148 See also Psychic phenomena Samuels, Mike, 263 Psychic phenomena, 161-174, 206- Sanitary systems, 106, 196 207 Sargent, Fredrick, 190 Psychoactive drugs, 115 Sartre, Jean Paul, 147 Psychokinesis, 162, 165-166, 169 Scheff, David, 241 Psychology, 114-115 Schoen, Donald. See Schwartz, Jerome, 221 also Treatment, individualversus Scrimshaw, Nevin, 244 population Sedgewick, Peter, 230 Public health service, 94 Segal, Ronald, 145 Puharich, Andrija, 146-147 Self-care, 67-70, 131, 133, 135, 152, Puritan Massachusetts, 116 158-159, 183-184 Puthoff, Harold, 261 Selye, Hans, 84 Service institutions, 128-132,136, Quackery, 222-225 139-140, 174-177 Quinn, R. Surgeons, England and Wales, 9 See also Public attitudes number of, 9 Vesalius, 203 United States, 9 Virbrations, light, 170-173 Surgery, incidence rates, 9, 12-13 sound, 170, 173 post-operative mortality, 9 -1 0 Virchow, Rudolf, 192, 203, 231 Swami Rama, 66 Vithoulkas, George, 249 Sweden, medical care in, 47, 51, 246 Voltaire, 6 Systems analysis, 124 Szasz, Thomas, 116 Wallace, Robert K. Fuller, 257 Tranquilizers, 16 Yankelovich, Daniel, 148-149 Treatment, costs, 98 Yoga, 68-69 individual versus population, 33, 205-206, 211,222-224 Zero Population Growth, 81 versus prevention, 17, 26—29, 36, Zola, Irving K. Kelly* for my start in psychiatry; for Bryan Alton* for a good start in medicine; for Mark Hartman* who introduced me to the idea that unpaid work can be rewarding; for Jim Maguire* who made us laugh at adversity; and, for my parents Michael* and Theresa* for doing far more than their duty. No part of this title may be reproduced or transmitted in any material form (including photocopying or storing in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner and the College of Psychiatry of Ireland. The College of Psychiatry of Ireland approached the author through its president Justin Brophy to make it available on-line. This request immediately struck the undersigned as being eminently more sensible than having it expand anonymously on his personal computer.

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