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By: O. Cobryn, M.B. B.CH., M.B.B.Ch., Ph.D.
Vice Chair, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine
Herodotus says that the Egyptians of his days were black men: very possibly; but neither before nor since his period has this remark been found to be true blood pressure 15080 cheap 12.5mg lopressor. The paintings on the tombs and the mummies en tombed alike refute his assertion hypertension 90 lopressor 100 mg discount, if extended beyond his period blood pressure medication most common lopressor 100mg with mastercard. He gossiped blood pressure chart mayo discount lopressor 100 mg otc, I am afraid, like some other travellers, and talked a good deal about what he did not understand. His story about the Persian skull reminds me of the next assertion of ancient and modern phy siologists, of the supposed influence of external, even mechanical, means over the human form. It is to Hippocrates we owe the story of the Macrocephali, inhabiting at that time the shores of the Euxine. They were a race with narrow, elongated, elevated heads and depressed fore heads, like the American Indians, or copper coloured race, and more especially like the Carib and the Chenook. That the Carib and Chenook, and the ancient Macrocephali, fancied that by pressure they could give to the human head what form they chose, is certain enough; but does it follow that they could do so The form of the head I speak of is peculiar to the race; it may be exaggerated some what by such means, but cannot be so produced: neither will such deformation become hereditary. For four thousand years have the Chinese been en deavouring to disfigure the feet of their women: have they succeeded in making the deformation permanent Corsets have been worn time out of mind: Galen complains of them; he ascribes to them all sorts of bad results, deformities of spine and chest. For how long have the Jews, with most African and Eastern nations, practised circumcision Is there any instance of such accidental or mechanical deformities becoming transmissible by hereditary descent Varieties in form proceed only to a certain length- they are constantly checked by two laws, the laws maintaining species as they exist- 1, the tendency to reproduce the specific form instead of the variety; 2, non-viability or non rcproduction, that is, extinction. This it is which checks deformations of all kinds, and I even think I have observed varieties in form to be more common in those who die young than in those reaching adult years, as if the very circumstance of these internal deformations or varieties, however unimportant they may seem, coincided at least, if they were not the efficient cause of early decay of the vital powers and of premature death. Had the heads of the Macro cephali of ancient times, and of the Carib and Chenook and Peruvian of modern, owed their forms to mechanical means, that form would and must have ceased with their immediate descend ants, or the race would have perished. How much more singular is the fact, that there should exist naturally men with beads and brains so singularly shaped; that it should be in their nature; that the form should still persist-un alterable, dependent on no climate, Asiatic- American; ancient and modern. It was Herodotus who said, that on a field of battle it was easy to distinguish the Egyptian from the Persian skull, the former being hard, the latter soft. Herodotus must, I think, have studied medicine; he gives a reason in such a pleasant, off-hand way for all natural phenomena. The reason he assigns for this difference is, that the Persians covered the head-the Egyptians used no head-dress. Admitting both facts to be true, and I doubt them both, the reason given explains nothing; if there was a difference, it depended on race. The Copt was African; the Persian, Asiatic: they were different races of men-that is all. The theories and the errors of Hippocrates and Herodotus linger in the physiological schools to this day. Foville, for example, ascribes to mechanical pressure on the head of the infant, the wide hollow groove occasionally traversing it over the region of the vertex, and so frequently persisting to the adult state-a deformation wholly independent of such a cause, and oc curring in all countries. Key per sisted in blaming tight and short shoes for the most common deformity of the feet; and Dr. I put these three observations, but not the writers, under the same category; the last is refuted by every observation, and is below notice. To Hippocrates, then, as representing the entire class of physiologists, we owe most of the medical, philosophical, and theo-philosophical notions of the present day; the theories which teach that cities looking to the west differ very materially from cities looking to the east, as also their inhabitants; the reason why Asiatics differ from Europeans-not one word of which is true; how in a country where the seasons and climates ditfer much, the inhabitants also must difl`er much, the reverse of which is nearer the truth: to him we owe the theory, that people living under a monarchy are servile and cowardly, whilst republicans are bold and brave-a doctrine which certainly has some little show of truth, and which we may afterwards discuss. His theories be transmitted to the scholars of Greece; they affected even Aristotle, a. And this reminds me of a mysterious law in nature, not yet fully investigated, to which I next beg to call your attention. Can a race of men permanently change their locality-say Continental, or rat/zer- Ter restrial Zone
The nerve lies first under abductor hallucis blood pressure specialist buy discount lopressor 25mg on-line, then hypertension quotes buy 50mg lopressor amex, in company with the lateral plantar vessels blood pressure readings order lopressor 50 mg otc, it passes across the sole of the foot to the base of the 5th toe blood pressure medication ingredients lopressor 25mg line, the Sacral and Coccygeal Plexuses 205 lying between flexor digitorum brevis (in the first layer of the muscles of the sole) and flexor accessorius (in the second layer). At the lateral side of the foot, the plantar digital branches have their origin; the deep part of the nerve, still accompanied by the vessels, continues back across the sole between adductor hallucis (third layer of muscles) and the interossei (fourth layer). The lateral plantar nerve supplies the following: 1 Muscular branches to: (a) all the interossei; (b) lumbricals 2, 3 and 4; (c) adductor hallucis; (d) flexor digiti minimi brevis; (e) flexor accessorius; (f) abductor digiti minimi. The common peroneal (lateral popliteal) nerve (L4, 5, S1, 2) is one of the two terminal branches of the sciatic nerve, and it is but half the diameter of the tibial nerve. It then winds round the neck of the fibula, deep to peroneus longus, there to divide into its terminal branchesathe deep peroneal and the superficial peroneal nerves. The sural communicating nerve arises from the common peroneal nerve in the popliteal fossa, descends over the lateral head of gastrocnemius to join, and be distributed with, the sural nerve (see p. Occasionally it fails to communicate and, as an independent nerve, it then supplies the skin over the lateral side of the leg and ankle. It can be palpated against the neck of the fibula and is the only palpable nerve in the lower limb. The lateral cutaneous nerve of the calf also arises in the popliteal fossa and also descends over the lateral head of gastrocnemius. It supplies the skin over the anterolateral and posterolateral aspects of the upper calf. It passes deep to the upper part of extensor digitorum longus to reach the anterior aspect of the interosseous membrane. It descends on this membrane, then on to the lower third of the front of the tibia and finally crosses the front of the ankle joint before breaking up into its terminal branches. However, extensor hallucis longus arises from the second and third quarters of the shaft of the fibula medial to the extensor digitorum longus and therefore becomes the lateral relationship of the nerve; tibialis anterior remains throughout as the medial relation. At the ankle the nerve is crossed obliquely from laterally to medially by the tendon of extensor hallucis longusathe tendon must do so to reach the great toe. The Sacral and Coccygeal Plexuses 207 Peroneus longus (cut) Tibialis anterior Extensor digitorum longus Saphenous branch of femoral N. Since these pass above the interosseous membrane at its origin and the nerve hooks round the fibular neck, the nerve will obviously first lie on the lateral side of the vessels upon the interosseous membrane. About the middle of the leg, the vessels swing behind the nerve, but move back again to the medial side of the nerve in the lower third of its course. The deep peroneal nerve supplies the following: 1 Muscular branches to: (a) tibialis anterior; (b) extensor hallucis longus; (c) extensor digitorum longus; (d) peroneus tertius. At the web between these toes, the nerve divides to supply the dorsal aspects of the adjacent sides of the 1st and 2nd digits. It descends along the intermuscular septum between the peroneal muscles and the extensor group, first with peroneus longus and then brevis laterally and with extensor digitorum longus throughout on its medial side. The superficial peroneal nerve supplies the following: 1 Muscular branches to: (a) peroneus longus; (b) peroneus brevis. The Sacral and Coccygeal Plexuses 209 the medial terminal branch crosses the front of the ankle and then divides. The more medial division runs to the medial side of the hallux; the more lateral splits to supply the adjacent sides of the backs of the 2nd and 3rd toes. The lateral terminal branch supplies the dorsum of the foot, then gives two dorsal digital branches, one to the adjacent sides of the 3rd and 4th toes, the other to the adjacent sides of the 4th and 5th toes. A recapitulation of the innervation of the dorsum of the toes is thus: 1 suralalateral side of 5th toe; 2 deep peronealaadjacent sides of 1st and 2nd; 3 superficial peronealathe rest. However, there may be considerable encroachment laterally on the superficial peroneal territory from the sural nerve. Nerve blocks at the ankle Five nerves pass the malleoli at the ankle: the posterior tibial nerve, the sural nerve, the deep peroneal nerve, the superficial peroneal nerve and the saphenous nerve (see Figs 143, 144 & 146). All can be blocked with local anaesthetic, although the choice of nerves to be blocked for an individual patient will depend upon the site of surgery. The posterior tibial nerve is blocked immediately posterior to the medial malleolus as it runs just behind the posterior tibial artery.
For unexplained conditions lasting beyond 6 weeks arteria hepatica purchase lopressor 100 mg overnight delivery, experts recommend brief screening questions with high sensitivity and specificity hypertension code for icd 9 discount 50 mg lopressor fast delivery, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety arteria obstruida 50 purchase lopressor 25mg without prescription. Many of the terms used to describe the mental status examination are familiar to you from social conversation pulse pressure nhs order lopressor 50mg with mastercard. Take the time to learn their precise meanings in the context of the formal evaluation of mental status (see below). Terminology: the Mental Status Examination Level of Consciousness Attention Memory Alertness or State of Awareness of the Environment the ability to focus or concentrate over time on one task or activity the process of registering or recording information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years. Awareness of personal identity, place, and time; requires both memory and attention Sensory awareness of objects in the environment and their interrelationships; also refers to internal stimuli. Explore any unusual thoughts, preoccupations, beliefs, or perceptions as they arise during the interview. All patients with documented or suspected See Table 20-2, Delirium and Dementia, pp. Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling Screening for depression and suicidality Screening for alcohol, prescription drug, and substance abuse Mood Disorders and Depression. Lifetime prevalence of major depression meeting formal diagnostic criteria in the United States is approximately 7%. Primary care providers fail to diagnose major Chapter 5 Behavior and Mental Status 71 depression in up to 50% of affected patients, often missing early clues such as low self-esteem, anhedonia (lack of pleasure in daily activities), sleep disorders, and difficulty concentrating or making decisions. Failure to diagnose depression can have fatal consequences-suicide rates in patients with major depression are eight times higher than in the general population. Suicide rates are highest among men 75 years and older and are increasing among teenagers and young adults. More than half of patients committing suicide have visited their physicians in the prior month. More than 90% of suicide deaths occur in patients with depression or other mental health disorders or substance abuse. Risk factors include suicidal or homicidal ideation, intent, or plan; access to the means for suicide; current symptoms of psychosis or severe anxiety; any history of psychiatric illness (especially linked to a hospital admission); substance abuse; personality disorder; and prior history or family history of suicide. Patients with these risk factors should be immediately referred for psychiatric care and possibly hospitalization. The comorbidity of alcohol and substance abuse with mental health disorders and suicide are extensive. Alcohol, tobacco, and illicit drugs account for more illness, deaths, and disabilities than any other preventable condition. Lifetime prevalence of alcohol and illicit drug use in the United States is 13% and 3%. An estimated 3% are dependent on or abuse illicit drugs; of these, 60% use marijuana. Because screening for alcohol and drug use is part of every patient history, review the screening questions recommended in Chapter 3, Interviewing and the Health History. Test specific functions if indicated during the interview or physical examination. Aphasia, dysphonia, dysarthria, changes with mood disorders Testing for Aphasia Word Comprehension Ask patient to follow a one-stage command, such as "Point to your nose. For the fund of information, ask names of presidents, other political figures, or large cities. Calculating Abilities, such as addition, subtraction, and multiplication Abstract Thinking-ability to respond abstractly to questions about the meaning of proverbs, such as "A stitch in time saves nine" the similarities of beings or things, such as a cat and a mouse or a piano and a violin Constructional Ability. Ask patient: these attributes reflect intelligence, education, and cultural background. They are limited by mental retardation but are fairly well preserved in early dementia. Poor calculation in mental retardation and dementia Concrete responses (observable details rather than concepts) are common in mental retardation, dementia, and delirium. This brief test is useful in screening for cognitive dysfunction and dementia and following their course over time. Recording Your Findings Recording Your Findings c dn u n n s Recording Behavior and Mental Status "Mental Status: the patient is alert, well-groomed, and cheerful.
Next came the war of race heart attack 86 years old order lopressor 25 mg with amex, which must continue whilst race exists arteria renal buy 12.5 mg lopressor with visa, and war confined to no parti cular region radial pulse blood pressure 90 order lopressor 25mg on-line, but extended over the earth arteria ductus deferentis discount 25mg lopressor amex. But after all, the basis is difference in race, that key-stone to all human actions and human des tinies. It seems to me, that in claiming for the German so many works of merit, the illustrious Quetelet has not drawn a clear distinction,-I had almost said, has failed to observe, that Scandinavian or true German, that is, the classic German of antiquity, has no pretensions whatever to the literature he has assigned to the people he calls German; that the whole of it is either South Ger man or Slavonian. There is the less occasion then for ascribing to them qualities they never possessed. That much of these high qua~ lities of mind, the appanage of the Middle and South German, is derived from their contact, and possibly, admixture, with the Slavonian, I am willing to concede; at one time I felt inclined to ascribe it wholly to the Slavonian, and did so in several courses of lectures. Defeated in their last great effort, extending from Baden to Vienna, the fate of the German people or race I now speak of is uncertain. In their last struggle, the best Scandinavian blood stood aloof; no Gustavus appeared to lead them to victory; no such person, perhaps, ever belonged to their race. They die out of course, or return to the pure races; but this I will say, that in no instance have I ever observed them to bear any resemblance to the modern Middle and South German. They have not told you that the true Germans always rejected the head of this empire, refusing to acknowledge him or it as their head; that the political union was a jumble of heterogeneous materials, ready to fall to pieces before an invad ing force; and that like every fraud on sense and nature, the artificial and unnatural power would cease to be. Accordingly, the Austrian empire fell before a mere handful of men, who would no longersubmit to be the most wretched of all slaves; the emperor fled from his palace; the sagacious and far-seeing Metternich had no advice to give, no aid to offer. He was the first to run: he, who for thirty years had enjoyed the plunder of a most rich and fertile territory, inhabited by more than thirty mil lions of industrious and most intelligent people; he, when the hour of danger came, had not a friend to strike a blow in his defence. Recovering from their panic they were next overthrown by a hand ful of Hungarians: all but beaten out of Italy, and finally rescued by the gold and bayonets of another race; to endure, or be endured, for a short time longer, and then to cease for ever. When I predicted some years ago the certain downfal of the Houses of Hapsburgh and Brandenburgh, and the ap proaching conflict between dynasties and races, l was told that the kingdom of Prussia was a strong and united kingdom-consolidated: that all distinction of race had long disappeared: that it was the same with Austria: that these drum head governments were the very best in the world; the people educated and happy; models, in short, for the British people. But this profound igno rance of the actual state of Europe would now seem to have been confined to Britain, and per haps to France: the Slavonian and German questions were perfectly well understood and acted on by the various dynasties; especially was it essential for the Houses of Hapsburgh and Brandenburgh, to prevent the agitation of these two questions-to break up these two, or, rather as they may now be viewed, three races, the Saxon or Northern German, the Southern German, and the Slavonian: it served the views of a fourth race-above all, the Sarmatian -a race grasping at the possession of the ancient world. Whilst looking at the map of Europe, some twelve or fifteen years ago, and recalling, in as far as I could, the narrative of a few centuries; the causes assigned for triple and quadruple alli ances, and their probable real causes-the osten sible reasons for wars and partitions of states, the thought occurred to me, May not the question of race explain some of these, to me otherwise inexplicable, historical events It was in the course of this inquiry, that I ascertained that a race of men, whose history is still to write, of whom we know neither their physical structure nor mental qualities, ex tends from the mouth of the Danube, occupying both. There are some who stickle for the fusion of races, placing them in a Utopian theory of progress: let them try the question by the Slavonian race. The stieklers for the amal gamation of races had better try the question in Posen, or Finland, or Prussia, or Austria; in what number of centuries do they look for such an event The position of the Slavonian has been known for fifteen centuries, and may be guessed at for fifteen more, yet we have no visible signs of amalgamation, nor any explanation of the fact, unless by the falsifying of historic facts. Little seems to me to be known of this noble race, the most intellectual, probably, of all. They are said to be remarkably deficient in elegance of form; external beauty does not belong to them, according to some; they are short in stature, with dark hair and complexion-cheerful in disposition and fond of pleasure. The element of mind which leads to transcendentalism is distinctly Slavonian-at least, so it seems to me. The rationalism of Strauss belongs to no Scandinavian; Oken was not a Saxon; nor Spix; nor Von Martius: Bathyani and Kossuth are not Germans: De Haen was a court physician in Vienna about a century ago; he wrote on magic! In my younger days I was taught, as most have been, no doubt, that the Caucasian family was one-the Caucasian nations, of one race, of one mind therefore; this, I think, is a fair deduction from the premises. The future destiny of the Slavonian race is, if possible, more problematical than any other. About eighty millions in number, they groan under the despotisms of three dynasties or families-Haps burgh, Brandenburgh, and the Muscovite. Part belong to the Mahomedan of Turkey, with whom it would seem that honour and humanity, and common sense, driven from civilized (l) Europe, are about to make their last stand. It would seem that the Ban Jellaehich is their hereditary chief, but he let the golden opportunity slip through his fingers-betrayed, no doubt, by the court of Vienna. Still the Slave nians demand a political unity-the South Ger man does the same; the North German or Scandinavian despises them both, but he also would fain be free.
The critical appraisal of the evidence enables us to determine to what degree we are confident that: 1) the specific assessment questions can be answered conclusively; and 2) the intervention will improve health outcomes for patients heart attack symptoms in women quality 12.5 mg lopressor. An improved health outcome is one of several considerations in determining whether an item or service is reasonable and necessary blood pressure z score calculator order 100mg lopressor free shipping. A detailed account of the methodological principles of study design that the agency utilizes to assess the relevant literature on a therapeutic or diagnostic item or service for specific conditions can be found in Appendix B arrhythmia kamaliya download order 25mg lopressor otc. In general hypertension webmd lopressor 50mg on line, features of clinical studies that improve quality and decrease bias include the selection of a clinically relevant cohort, the consistent use of a single good reference standard, and the blinding of readers of the index test, and reference test results. Public comments that give information on unpublished evidence such as the results of individual practitioners or patients are less rigorous and therefore less useful for making a coverage determination. Public comments that contain personal health information will not be made available to the public. In this coverage analysis, we considered destination therapy studies and evidence that were published since the last reconsideration in 2007. In addition to these outcomes of interest, we are focusing on information related to patient selection criteria so patients can be appropriately and carefully selected for the procedure. Advanced heart failure treated with continuous-flow left ventricular assist device. The primary composite endpoint of the study was 2 years post-implant survival, free of stroke resulting in a Modified Rankin Score > 3 or reoperation to repair or replace the device. The Modified Rankin Score is a functional assessment that ranges from zero (no symptoms at all) to six (dead). Symptoms of cardiac insufficiency or of the angina syndrome may be present even at rest. Results: the patients in both arms had similar baseline characteristics (Table 1): Table 1: Baseline characteristics of the study patients, according to treatment group (Slaughter et al. The primary endpoint (2-year post implant survival free of stroke) of the pivotal study reported on an intent to treat basis was met by 62 of the 134 patients (46%) in the continuous-flow device arm and 7 of the 66 patients (11%) the pulsatile device arm. Functional status and quality of life, reported on an as-treated basis, according to time since device implant (Slaughter et al. Page 11 of 42 126 0 0 4 (3) 27 (21) 95 (75) 91 30 (33) 38 (42) 16 (18) 5 (5) 2 (2) 72 30 (42) 25 (35) 13 (18) 4 (6) 0 50 21 (42) 19 (38) 6 (12) 1 (2) 3 (6) 3Mo 12Mo 24Mo Baseline Six Minute walk No. We have not reproduced the data for the pulsatile device as it is not the subject of this decision. Adverse events and associated relative risks were reported on an as treated basis with results for the continuousflow device patients showing lower risk in all measures (not all were statistically significant). Lowered risk reached statistical significance for pump replacement, sepsis, medical management (with inotropes) of right heart failure, respiratory failure and renal failure. While continuous-flow patients demonstrated lower risk, their absolute adverse event rates are important to note. Randomization was stratified by study center and blocked to maintain the 2:1 ratio over time. Patients meeting the study endpoint were considered a success and a failure if not. Results:Reasons for patient ineligibility for transplant included age (28%), recent cancer history (9%), obesity (7%), and substance abuse or insufficient social support (7%). Table 4: As treated analysis of patient survival at 2 years by original implanted device. Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. No information about overall survival or complications is reported in this article. Prognostic significance and measurement of exercise-derived hemodynamic variables in patients with heart failure. This review article discusses the need for reliable prognostic indicators for evaluation of candidates for heart transplant in view of the widening gap between number of surgical candidates and available organs.
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