Mark Corson

By N. Ronar. Thomas Edison State College.

The industrial science establishment is a relatively small and incestuous group; the many committees and organisations which form it frequently exchange members to carry out different projects order 20mg abilify. The Association is a nationwide group set up in the nineteenth century by men predominantly from the large industrial cities discount 20 mg abilify otc, as a forum for scientific ideas generic abilify 10 mg on line. Such a sense of exploratory amateurism has died out now that science inhabits the high risk, high profit world of industrial professionals. It does, however, appear to have some influence with Nature and the New Scientist. Over the last few years they have held a series of one-day conferences at which scientists get to know how the media work. In 1989, Sir Walter Bodmer was a Vice-President, having been appointed to the committee by another influential institution, the Royal Society. It was set up in the late seventeenth century and has since that time acted as a club for the aristocracy of science. Royal Fellows of the Society have included Prince Philip, the Prince of Wales, Queen Elizabeth the Queen Mother and in 1971, His Majesty Emperor Hirohito of Japan. Sir Walter Bodmer was elected a Fellow of the Royal Society in 1974 and since that time he has played an active role in its affairs and committees. In 1985, a Press Briefing Committee was set up by the Royal Society and the Association of British Science Writers. It was to consider topics for scientific press briefings and to oversee their organisation. The first Chairman was Sir Walter Bodmer, who was chosen in 1985 and again in 1987. In 1987, Caroline Richmond, who two years later was to become founder of the Campaign Against Health Fraud, was elected onto this committee by the Association of British Science Writers. In 1991 the committee was enlarged with five members for each organisation, and Sir Walter Bodmer was replaced by Professor Lewis Wolpert. Despite the fact that she was neither a clinician nor a practising scientist, Caroline Richmond had become accepted at the very centre of the scientific establishment. One aspect of laboratory scientific work which links many scientists together is their defence of animal experimentation. We are adopting a mainly catalytic role and are trying, with some success, to enlist the help of those who are, or should be, our natural allies. Chief amongst these are scientists, especially those engaged in biomedical research, doctors and surgeons, paramedical staff, patients and 2 patient associations and medical charities. Since the failure of the Ministry for Science and Industry in 1964, science and scientists in Britain have been left to their own devices. Without representation, the various Science Research Councils which receive money directly from the government have frequently had their grants cut. With less government money available for science, industry has stepped into the breach and academics and industrialists have ended up fighting the corner for science. After the election of the second Conservative government under Margaret Thatcher in 1983, this situation began to change. Industry wanted some return for its championing of science, and it particularly wanted more money from government for research and development. Many of the science-orientated campaigning groups were re-invigorated in this period and a push began to create a more formal governmental control over science policy. This was set up in 1939 to take over the functions of the Parliamentary Scientific Committee which was suspended at the outbreak of war. This all-party group consists of members of both Houses of Parliament and the European Parliament, representatives of scientific and technical institutions, industrial organisations, science-based companies, and academia. The Parliamentary and Scientific Committee is in some ways a misnomer, for the Committee is actually eight groupings, which include universities and industrial corporations, with a total of nearly six hundred members. Not surprisingly, many of the individuals who champion science and industry and defend the ideology of science are parties to this seminal scientific committee. In 1987, Sir Hermann Bondi, the head of the British Humanist Association, was one of its Vice-Presidents. The Wellcome Trust and the Wellcome Foundation are represented, as are the Royal Pharmaceutical Society, the Society of the Chemical Industry and the World Sugar Research Organisation. The Royal College of Surgeons is represented by Sir Stanley Peart, a Wellcome Trustee, the Imperial Cancer Research Fund by Sir Walter Bodmer. The Institute of Food Technology is represented by Professor Arnold Bender, and the Biochemical Society by Professor Harold Baum, both Campaign Against Health Fraud members. The British Nutrition Foundation and the British Dietetic Association are both represented, as is the British Association for the Advancement of Science. The Association of Medical Research Charities, a Wellcome-administered umbrella organisation, has two representatives on the general committee. In the last five years, the Committee has been addressed by, amongst others: Lord Sherfield; Professor David Conning, Director-General of the British Nutrition Foundation; Professor C. Gordon Smith, a Wellcome Trustee and Dean of the London School of Hygiene and Tropical Medicine, and Margaret Thatcher. Our work is increasingly engaged in trying to understand issues such as health, pollution, international trade, education research, national defence conversion and energy strategy in the framework 4 of how each relates to the more fundamental issues of economy, security and environment. Appropriate action through parliamentary channels wherever necessary to reinforce the views expressed by members on matters of public interest and legislation, especially for financing scientific and technological research, education and development, and to ensure that the proper regard is had for the scientific point 5 of view. More recently, the magazine began to include feature articles by members of the committee and other prominent people in science, industry and Parliament. Science in Parliament is published by an outside publisher, Westminster Publications. Recent issues have been sponsored by the British Technology Group and some by Hoechst, the drug company.

Pentoxifylline abilify 15 mg on line, a substituted xanthine derivative that increases erythrocyte elasticity discount 15 mg abilify overnight delivery, has been reported to decrease blood viscosity buy abilify 20 mg without a prescription, thus allowing improved blood flow to the microcirculation; however, results from clinical trials are conflicting, and the benefit of pentoxifylline, if present, appears small. It has been shown in randomized controlled trials to improve maximal walking distance. This can be accomplished by percutaneous angioplasty, with or without placement of intraarterial stents, or surgical bypass grafting. Angiography (either conventional or magnetic resonance arteriogra- phy) should be performed to define the flow-limiting lesions prior to any vas- cular procedure. Ideal candidates for arterial revascularization are those with discrete stenosis of large vessels; diffuse atherosclerotic and small-vessel disease respond poorly. Less common causes of chronic peripheral arterial insufficiency include thromboangiitis obliterans, or Buerger disease, which is an inflammatory condi- tion of small- and medium-size arteries that may affect the upper or lower extremities and is found almost exclusively in smokers, especially males younger than 40 years. Fibromuscular dysplasia is a hyperplastic disorder affecting medium and small arteries that usually occurs in women. Patients with chronic peripheral arterial insufficiency who present with sudden unremitting pain may have an acute arterial occlusion, most com- monly the result of embolism or in situ thrombosis. The heart is the most common source of emboli; conditions that may cause cardiogenic emboli include atrial fibrillation, dilated cardiomyopathy, and endocarditis. Artery-to- artery embolization of atherosclerotic debris from the aorta or large vessels may occur spontaneously or, more often, after an intravascular procedure, such as arterial catheterization. Emboli tend to lodge at the bifurcation of two vessels, most often in the femoral, iliac, popliteal, or tibioperoneal arteries. Arterial thrombosis may occur in atherosclerotic vessels at the site of stenosis or in an area of aneurysmal dilation, which may also complicate atherosclerotic disease. Patients with acute arterial occlusion may present with a number of signs, which can be remembered as “six P’s:” pain, pallor, pulselessness, pares- thesias, poikilothermia (coolness), and paralysis. The first five signs occur fairly quickly with acute ischemia; paralysis will develop if the arterial occlu- sion is severe and persistent. Rapid restoration of arterial supply is mandatory in patients with an acute arterial occlusion that threatens limb viability. Initial management includes anti- coagulation with heparin to prevent propagation of the thrombus. The affected limb should be placed below the horizontal plane without any pressure applied to it. Conventional arteriography usually is indicated to identify the location of the occlusion and to evaluate potential methods of revascularization. Surgical removal of an embolus or arterial bypass may be performed, particularly if a large proximal artery is occluded. Alternatively, a catheter can be used to deliver intraarterial thrombolytic therapy directly into the thrombus. In comparison with systemic fibrinolytic therapy, local- ized infusion is associated with fewer bleeding complications. Which of the following therapies might offer him the greatest benefit in symptom reduction and in overall mortality? She is evaluated by the cardiovascular surgeon but not felt to be a surgical candidate. Cilostazol may help with claudication symptoms but will not affect cardiovascular mortality. Thromboangiitis obliterans, or Buerger disease, is a disease of young male smokers and may cause symptoms of chronic arterial insufficiency in either legs or arms. Takayasu aortitis is associated with symptoms of inflammation such as fever, and most often affects the subclavian arteries, produc- ing stenotic lesions that may cause unequal blood pressures, dimin- ished pulses, and ischemic pain in the affected limbs. Embolism of cholesterol and other atherosclerotic debris from the aorta or other large vessels to small vessels of skin or digits may com- plicate any intraarterial procedure. Surgical therapy is reserved for severe symptoms after exercise and pharmacologic agents are used, and quality of life is impaired. Pain at rest, lack of symptoms for medical therapy, nonhealing ulcers, or gangrene are some of those indications. Duplex ultrasound can help to discern whether the patient is a potential surgical candidate. Diffuse atherosclerotic disease is a contraindication for surgery since bypass would not help in the face of significant and widespread disease. Clinical Pearls ➤ Smoking cessation is the single most important intervention for athero- sclerotic peripheral vascular disease. Other treatments include pentoxi- fylline or cilostazol, regular exercise, and cardiovascular risk factor modification. Chronic incom- plete arterial occlusion may result only in exertional pain or fatigue, pallor on elevation of the extremity, and rubor on dependency. Seven years ago at a work-related health screening, he was diagnosed with hyper- tension and hypercholesterolemia. At that time, he saw a physician who prescribed a diuretic and encouraged him to lose some weight and to diet and exercise. During the past 2 months, he has been experiencing occa- sional headaches, which he attributes to increased stress at work. He denies chest pain, shortness of breath, dyspnea on exertion, or paroxys- mal nocturnal dyspnea. He smokes one pack of cigarettes per day and has done so since he was 15 years old.

In a retrospective analysis of still- optimal glycemic control preconception buy 15mg abilify, but should be considered during the preconcep- births occurring in women with type 1 diabe- to have a negative impact on long-term renal tion assessment for all women with longstand- also in preparation for the early weeks of preg- tes 20mg abilify amex, a six-fold higher incidence of nephropathy function in women with diabetic nephropathy ing type 1 diabetes and all women with type nancy discount abilify 20 mg visa. Assessment of renal function creatinine) in contrast to those with low cre- 47,48 should be considered if other risk factors are Due to the increased frequency of hypogly- with serum creatinine, estimated glomeru- atinine clearance before pregnancy. Prompt return to normogly- be performed in all diabetic women prior to Other complications of diabetes Eating disorders associated with diabetes cemia, after hypoglycemia, may help to reduce conception. Sensorimotor The possibility of disordered eating patterns, between hypoglycemia and congenital mal- neuropathy in women with diabetes rarely including binge eating and insulin restriction formations, but this has not been confrmed causes problems during pregnancy and does 53 to avoid weight gain should be considered dur- in human studies. Autonomic neuropathy is associ- First-line hypoglycemia treatment should be Normal Unknown ated with hypoglycemic unawareness, which Hypoglycemia, usually defned as blood glu- consumption of fast-acting carbohydrates such <30 mg/24 hours can be aggravated by pregnancy. Women need to be aware Once blood glucose levels have recovered, fur- 30–300 mg/24 hours who have developed gastroparesis as a compo- that the tight control required before con- ther hypoglycemia should be avoided by con- Macroalbuminuria Increased pre-eclampsia nent of autonomic neuropathy often have poor ception, and in pregnancy, may predispose sumption of longer-acting carbohydrates such >300 mg/24 hours 49,50 metabolic control and inadequate nutrition. Evers as a cereal bar, fruit, biscuits or the next meal Protein excretion Increased risk of This complication is subsequently associated and colleagues demonstrated that the fre- if it is due. Women should be clearly at the preconception appointment, not least appointment in the antenatal clinic, as each nancy with a general increase as pregnancy informed that if they have high blood sugar because many of these effects can be modifed 1% decrease in preconception HbA1C halves progresses, although this effect varies between levels with ketones, or evidence of urinary by improving diabetic control before concep- the rate of adverse pregnancy outcomes7. There appears to be a triphasic ketones with even moderate blood sugar eleva- tion and maintaining good control throughout Women with long-term diabetes are at pattern of insulin requirements, which remain tions, they should seek medical help urgently the pregnancy. Unfortunately both miscarriage greater risk of developing pre-eclampsia than steady in the frst trimester and increase there- rather than attempting to manage the situa- and fetal anomalies are much more common the background population, and this risk is after55. Unfortunately, since both proteinuria in a prospective study of women with type 1 recognized, and explained to women that both and hypertension are common in pregnan- diabetes, after initial increases in insulin doses Many women with diabetes are not aware that miscarriage and fetal anomalies are not exclu- cies with long-term diabetes, it can be diff- a fall in insulin requirements was observed there is no reason why they should not breast- sive to pregnancies in diabetics, or those with cult differentiating between this phenomenon between 7 and 15 weeks’ gestation56. Unfortunately, changes, in combination with the need to bal- aged, in the interests of both the mother and A comparison of miscarriage rates in 386 these complications cannot be prevented by ance near normal glycemic control with avoid- her baby. Regard- ance of hypoglycemia, result in the need for the preconception appointment and stressed reported a 16% miscarriage rate in both less, there are advantages in discussing these intensive blood glucose monitoring through- throughout antenatal care appointments. Accord- HbA1C level within the normal HbA1C range, in rin (see above), can be considered and poten- Diabetic ketoacidosis ingly, breastfeeding diabetic women should be the above normal range the miscarriage rates tially started early. In a macrosomia, leading to the birth of the clas- more susceptible to diabetic ketoacidosis aware that they can continue taking metformin smaller study of 83 type 1 and type 2 diabetics, sic cherubic infants of diabetics. Kamalakannan and associates reviewed or glibencamide whilst breastfeeding, because 95% of the miscarriages occurred in women they are often unaware that the risk of mac- contributing factors such as increased insu- there is adequate information on the safety of with an HbA level of more than 11. As data including maternal age, duration of diabetes, the pregnancy, especially in the third trimes- which include infection, vomiting and poor on the safety of breastfeeding with the other parity and smoking, and found a relative risk ter. Similarly, a comparison of type 1 dia- restriction can also complicate the pregnan- ops quickly and may be associated with less with these agents before pregnancy are usu- betics with an early pregnancy HbA1C above or cies of women with diabetes and can have marked hyperglycemia than is usual outside ally advised to stay on insulin until they have below 7. It has frequency, risk factors and long-term effects evidence of fetal growth restriction was asso- College of Obstetricians and Gynaecologists long been common practice to advise women of neonatal hypoglycemia, 9. A randomized even with well controlled diabetes delivery have written guidelines for blood sugar man- maternal trauma during delivery with mac- controlled trial of 200 women with insulin- should be considered after 38 weeks (see agement of the neonates of diabetic women8. Both studies found an increase in inevitable as shown by the cesarean section will help the baby maintain its blood glucose enquiry1 reported shoulder dystocia in 7. Neonatal blood glucose testing, pref- of vaginal births in diabetic women, with no cia in the expectant management group, with ing diabetes (40% in 2006 and 42% in 2007). It is thus appropriate to briefy dis- blood glucose level does not improve with less accuracy of estimated fetal weight is worse in Unheralded intrauterine death remains a cuss neonatal management during preconcep- invasive measures8. Neither shoulder dystocia nor in pregnancies complicated by diabetes mel- be reassured that, although the babies of dia- magnesemia, previously unrecognized con- the possible sequelae for the fetus (Erbs palsy) litus. Unfortunately, conventional tests of betic women require careful monitoring and genital heart disease and cardiomyopathy are can always be prevented, but awareness of the fetal well-being are poor at predicting these should therefore be delivered in a unit with all more common in the babies of women possibility and proper and timely management events8. Women may be tor for neonatal hypoglycemia, and, though less of diabetic mothers can be monitored for rare drills for all labor ward staff in its manage- aware of this statistic before they conceive and likely, can still occur in the babies of mothers neonatal complications, and to ensure that the ment. Diabetes in pregnancy: management The effectiveness of glibenclamide in women Developmental toxicity of the angioten- of diabetes and its complications from precon- with gestational diabetes. Pharmacokinetic and pharmacody- 2005;112:710–12 Optimal management of diabetes mellitus is (reissued July 2008) namic advantages of insulin analogues and 30. A Reference Guide to domized trial of active induction of labor and rin for the prevention and treatment of pre- function in nephropathic type 1 diabetic Fetal and Neonatal Risk, 7th edn. For exam- mine agonists, macroprolactinomas (diameter ple, only 11 out of 246 women with a micro- >10mm) may be challenging in this respect prolactinoma displayed asymptomatic tumor progression during pregnancy, and none neces- because of compression and invasion of the sitated surgical intervention owing to tumor surrounding vital structures, recurrence after growth5. Under such Effect of pregnancy on circumstances, it may be advisable for a patient prolactinoma growth with a macroprolactinoma to be operated or irradiated before planning of pregnancy. Prolacti- fetal growth and development nomas tend to enlarge during pregnancy prin- cipally by two mechanisms: (1) loss of shrink- A major concern regarding the management of age effects of dopamine agonists after their a prolactinoma during pregnancy is the safety of withdrawal upon diagnosis of pregnancy; and use of dopamine agonist drugs. The patient women with macroprolactinomas is much ration is highly likely (90%) with use of such cabergoline upon a missed menstrual cycle in more complex, being primarily based on the should then be informed about a small risk agents, most women have been exposed for patients with prolactinoma to make sure that extent and size of the tumor. Since macropro- of tumor enlargement induced by pregnancy- 2–3 weeks when the diagnosis of pregnancy the fetus does not become exposed during the lactinomas tend to be invasive, pregestational associated hormonal changes. As Fewer, albeit more discouraging, data exist to the sellar region or shows a small infrasel- that she should immediately notify her physi- some prolactinomas grow during pregnancy, it regarding the safe use of pergolide in preg- lar extension, then dopamine agonists may be cian if any change in visual acuity or a defect 4 would be advantageous to shrink the tumors nancy. After discuss- and Monka reported the results of a 4-month ing fertility in patients with prolactinoma who wishes to do so, a magnetic resonance imaging ing the risk of progression with the patient, to 9-year follow-up of 988 children exposed desire pregnancy. The incidence of spontaneous golide, its use also seems to be unsafe in preg- which there has been suffcient shrinkage may Conversely, the patient may have developed abortions, ectopic pregnancies and congenital nancy. In a review of 176 pregnancies during be handled in accordance with the principles signs and symptoms suggestive of tumor pro- 4 malformations in pregnancies during which which quinagolide had been used for a median mentioned above for microprolactinomas. In such instances, reinstitution, and newer compounds like cab- apy should not be instituted in women with a usually increase further after that period9.

For these reasons discount abilify 20 mg amex, they suit tude (see technique chapters abilify 20mg lowest price, particularly Chapters 7 buy 15mg abilify fast delivery, the methodology of naturopathic physical medicine 8 and 10). The lower ends of the spectrum are gentler (refer to Chapter 7 where such methods are described and less likely to cause reaction. Techniques can be in detail, for example under the heading ‘Positional applied for as little as a few seconds, up to hours in a release techniques’). For example, in myofascial release therapy, as soon as the tissue softens, the goal has been Constitutional issues reached. The interaction between treatment and patient is a In hydrotherapy, the temperature required might take critical one. Within each quickly, too forcefully or for too long – or inappropri- modality, there is a sliding scale of low to high appli- ately to the needs of the patient – will unsurprisingly cation of degree and duration, with ultimate responses have negative (or at least no positive) effects. The depending on complex interactions between the bio- make-up of the patient and the underlying constitu- mechanical influences being applied, and the unique tional influences are equally important. The notes on constitutional considerations in length of application to achieve the dose that does Box 4. Another benefit of dividing the dose over a principle, and reduces risk, is the use of patient educa- number of consultations is that the effect of the previ- tion and self-directed activities. When patients understand Another way of considering repetitive exposure to their condition, its causes and remedies, their comp- incremental ‘doses’ of physical treatment (e. The individual needs to gain applied stimuli offer a virtual training effect, as the an understanding of the multifactorial influences body or local tissues adapt to the treatment, in much associated with the onset, the aggravations and ame- the same way as weight training or athletic activity liorating factors of the condition, in order to prevent requires the body to gradually adapt to the training relapses and to heal appropriately. Although they reached broadly similar care, at least in regard to the first four steps in this conclusions, many are now regarded as outmoded but proposed therapeutic order, which appears to make it the most systematic of them provide useful guides to a core practice from both the principles of naturo- the intensity of treatment. These goals are not in any ing informed decision-making regarding therapeutic order, and each is reviewed and discussed in the and self-management strategies. The positive and nega- tive effects following treatment need to be managed skillfully, within the context of a global aim of optimal Detoxification healing. The process of healing should, if possible, A major goal in the general practice of naturopathic be: medicine is ‘detoxification’ of the individual. This concept requires a review of the physiology of this • gentle process and how this applies to physical medicine • individualized (Box 4. If an individual is in optimal health, it is considered that these initial provocations can be The proposed therapeutic order, as described in Chapter dealt with and fully resolved. The immune system, by 1, outlines a useful order of therapeutics that identifies specific or non-specific methods, enables the system the multiple layers and levels of healing. To maintain optimal physical and mental functions, the Reckeweg (1971) described this as the accumulation body has a complex network of enzyme reactions and of the products of intermediate metabolism at the site mechanisms to prevent the accumulation of the waste of a metabolic block. The toxemia theories have long been a central tenet of Detoxification physiology naturopathic medicine. Indeed, the intestinal mucosa may account done much to substantiate the views of those early for 25% of biotransformation, even before transport to pioneers (Newman Turner 1996). Phase I detoxification involves the mixed function The balance between the processes of assimilation oxidase system catalyzed by a number of enzymes, the and elimination is maintained by what Kollath (1950) most important of which are the cytochrome P450 family has described as ‘the flow equilibrium’ (Fig. These metabolize a wide range of lipid- Adequate circulation and drainage depend on the soluble substances in the liver, kidneys, lungs and skin. Toxemia in physical medicine Cell There is a growing body of evidence to suggest an association between exposure to toxic compounds and the etiology of a number of chronic conditions, in particular chronic fatigue syndrome, fibromyalgia and late-onset Parkinson’s disease (Perlmutter 1997, Sherer Circulatory Lymphatic Nervous et al 2002, Steventon et al 1989). Levine & Reinhardt (1983) suggest that chemical hypersensitivity is a manifestation of free radical peroxidative damage to cellular membranes resulting in Acid–base the release of inflammatory and immune mediators. Transit mesenchyme equilibrium Hydroxyl radicals also react readily with sugars which result in the prostaglandin and leukotriene release that promotes joint inflammation via the arachidonic acid cascade. Kjelsden-Kragh et al (1991) were able to demonstrate that patients undertaking a vegetarian diet Skin Lung Bowels Kidney (low in arachidonic acid) for 1 year following a fasting regime showed objective improvement in the symptoms Figure 4. Naturopaths view the immune system from a holis- of capillary into interstitium (Oncotic pressure is tic perspective and have always considered how other osmotic pressure created by plasma protein systems affect its functioning. This is particularly true molecules that are impermeable across the capillary of the effect of the psycho-emotional aspect on immune membrane). It is also true of the effect of the vessels that are distributed throughout the subcutane- physical tissues and their role in both cell-mediated ous layer. Pressure from the There are a number of osteopathic studies (Radjieski fluid surrounding the capillary forces these cells to et al 1998) showing effects of physical methods on separate, allowing fluid to enter the capillary. There enhanced immune function, and many of these are are one-way valves within the lymphatic capillaries described in Chapters 7 and 8, as well as in Chapter that ensure the continued one-way flow of the lymph 10. The normalization of movement, both structural in maintaining optimal health and healing. A brief review of lymphatic function is required from the lower limbs by, for example, the rhythmic to understand this approach. Physical therapies, including massage, have been Lymphatic function shown to affect the flow of lymphatic fluid. One example is the effect of decreased upper limb edema A primary influence on the immune response is the post mastectomy surgery (Mesina et al 1998). Increased lymphatic flow ment have been shown to: results in increased production and distribution of lymphoid cells (Mesina et al 1998). The volume of • enhance local circulation and drainage (Foldi & fluid exchange between the compartments of the body Strossenreuther 2003) is determined by Starling’s Law. This states (Guyton • reduce swelling and improve washout of & Hall 2006) that: inflammatory chemicals (Wittlinger & Hydrostatic pressure (capillary – tissue) – Oncotic Wittlinger 1982) pressure (capillary – tissue) = net fluid movement out • assist post-surgical recovery (Cantieri 1997). The massage including in patients with fibromyalgia and immune therapy was applied in 30-minute sessions, three function.