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They include China (1256 million) discount unisom 25mg overnight delivery, Europe 729 628 Latin America/Caribbean 504 809 India (982 million) purchase unisom 25 mg with visa, Indonesia order 25mg unisom mastercard, Brazil, Pakistan, Russian Northern America 305 392 Federation, Bangladesh, and Nigeria. The United States and Oceania 30 46 Japan also have more than 100 million inhabitants. These countries allocate resources to the health of their citizens, according to their means and priorities, as in Table 15. These figures point to the gross inequality between countries, which is further compounded by the inequality within each country. Source: World Health Report 2000, World Health therefore very scarce and priorities focus on maternal and child Organisation, Geneva health, investing in a strong primary healthcare system, HIV and Health expenditure per capita in AIDS, clean water, and sanitation. It is doubtful whether Country US dollars per year substantial resources will ever be made available for spinal cord injury care. The only way to ensure that a reasonable standard United States of America 4187 of care is offered world wide is to be innovative in devising a Switzerland 3564 strategy that will require as little financial means as possible. Germany 2713 France 2369 United Kingdom 1303 Manpower and staffing issues Brazil 319 Russian Federation 158 Nigeria 30 Rehabilitation medicine is often not as highly regarded as other Indonesia 18 specialities such as orthopaedic surgery. It may therefore be Pakistan 17 easier to find orthopaedic surgeons able to fix the spine, Bangladesh 13 whether or not it is indicated, rather than spinal cord injury Somalia 11 77 ABC of Spinal Cord Injury specialists. In many instances, surgery is isolated from rehabilitation, which might never be offered to the patient. Management of bladder, bowel and sexual function can be poorly organised, and skin care overlooked, leading to pressure sores. Patients can develop complications and die of chest or urinary infection or untreated autonomic dysfunction. Nurses will be attracted to areas that are less physically demanding and labour intensive in countries where the use of hoists is not widespread and manual handling of patients is necessary. Physiotherapists are not always adequately trained, and can sometimes be physical training instructors who have only had a few months’ training in the fundamentals of anatomy, physiology, and movement. The other difficulties relate to a very low level of salaries, lack of equipment, and Figure 15. This in turn may lead to demotivation and From The International Committee of the Red Cross. Social, psychological and architectural barriers Among the major obstacles to successful rehabilitation of spinal cord injury are social issues and the way society views disability. The social barriers include limited financial means available within the community, and the household not allowing survival (a) Preparing for a coordinated spinal lift (straight lift) in a tetraplegic. The way society views disability is a reflection of social and religious values. In certain cultures, disability is viewed as a punishment for past sins. In others, disabled people may not be allowed to enter certain religious sites if they are incontinent of urine or faeces and considered “unclean or soiled”. Religious considerations may be so important that—for patients not to be excluded from their environment—they dictate how the paralysed bladder and/or bowel will be managed. By acquiring a spinal cord injury, a person becomes part of a group he or she was previously looking down upon. Disabled people are at times hidden from mainstream life and cared for in a separate environment within the family dwelling. It is not common to see a disabled person going out shopping, to the cinema, or participating in active life. Little has been done to empower the individual or give him or her a voice. The tendency has been for charitable organisations to provide institutional help and care, thus appeasing social conscience, but not promoting dignity, individual expression, and choice. Some societies take pride in promoting the view that their system is acceptable, with the extended family taking up an active new, supportive role, but many problems exist “behind closed doors”. Hyperflexion or Hyperextension Mechanisms These less-common mechanisms of injury are often associated with other injuries to ligaments, such as the posterior cruciate ligament. Gender Issues During the past decade, the incidence of ACL injury in female athletes has increased more than the rate in male athletes. According to Arendt’s study, the injury rates in the National Collegiate Athletic Association 8 1.

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After that contribution he his foresight in safeguarding the leg from the was silent for 12 years purchase 25mg unisom mastercard, but at the age of 43 an moment of the accident until he reached his home buy unisom 25mg visa. It was in 1756 order unisom 25 mg visa, while riding in manuscripts of his lectures, but had published what is now known as the Old Kent Road, that an none of them. Sir James Earle, his son-in- imposed by convalescence in preparing for pub- law and biographer,3 relates that: lication and, once started as a writer, continued writing for over 20 years. His first work—“A He was thrown from his horse, and suffered a com- Treatise on Ruptures”—appeared in 1756, fol- pound fracture of the leg, the bone being forced through lowed by several others on diseases of the testi- the integuments. Conscious of the dangers attendant on cle, head injuries, curvature of the spine with fractures of this nature, and thoroughly aware how lower limb palsy, fractures and dislocations. Pott’s Fracture He sent to Westminster, then the nearest place, for two Chairmen to bring their poles; and patiently lay on the One of the important contributions to surgery by cold pavement, it being the middle of January, till they Pott was his monograph entitled “Some few arrived. In this situation he purchased a door, to which General Remarks on Fractures and Dislocations,” he made them nail their poles. He opposed the existing treat- caused himself to be laid on it, and was carried through ment by continuous instrumental traction, which Southwark, over London Bridge, to Watling Street, near St. I cannot forbear fracture could be best reduced and correction remarking, that on such occasions a coach is too fre- maintained by keeping the limb in such a posture quently employed, the jolting motion of which, with the that the muscles were continually relaxed. This unavoidable awkwardness of position, and the diffi- teaching had a far-reaching effect, for Pott’s culty of getting in and out, cause a great and often a method of treating fractures was generally fatal aggravation of the mischief. At a consultation of adopted in England and it prevailed for several surgeons, the case was thought so desperate as to generations. Pott, convinced that the fracture–dislocation of the ankle that now no one could be a proper judge in his own case, bears his name, with an illustration of the result- submitted to their opinion; and the instruments were ing valgoid-displacement of the foot and a actually got ready, when Mr. Nourse, who had been prevented from coming sooner, fortunately entered the drawing of the skeletal injuries responsible for it. After examining the limb, he conceived there His ascription is quite impersonal and he makes was a possibility of preserving it: an attempt to save it no mention of the fracture that he himself was acquiesced in, and succeeded. In consequence there has been some 275 Who’s Who in Orthopedics misapprehension as to the nature of Pott’s acci- vertebrae. His classical description of the ankle frac- origin elsewhere in the body: the disease was ture–dislocation, and his reticence about his own scrophula, and was capable of revealing itself in fracture of the tibia at a higher level, have misled a variety of organs. To give it a modern termi- many to believe that in describing the ankle injury nology, tuberculosis is an infective disease with he was speaking of something within his own inti- local manifestations. This misconception has helped The treatment of spinal disease had been to fasten his name to the fracture–dislocation. This was a new departure Palsy of the Lower Limbs which is frequently in treatment and was the first sign of understand- found to accompany a Curvature of the Spine and ing of the natural process of cure by osseous is supposed to be caused by it. But he was per- in 1779 and was translated into French and Dutch; suaded, partly by the inspiration of Hippocratic the disease that it described became known on the teaching, to form an artificial sinus by applying continent as “La maladie du Pott. He seemed confirmed in his view patients with their symptoms and signs with so by the frequent relief of paralysis in patients sub- sure a touch that we can add nothing to the mitted to this operation. He differentiated between flaccid and the object of draining an abscess, and indeed there spastic paralysis and noted that spasticity was the seldom is any superficial abscess in Pott’s para- invariable rule of spinal cord pressure in spinal plegia. The artificial sinus imposed recumbency, and in consequence of prolonged rest the paraly- The disease of which I mean to speak, is generally sis disappeared. Pott, like many of his successors, called a palsy, as it consists in a total or partial aboli- failed to realize the decisive importance of rest. It tion of the power of using, and sometimes of even was not until nearly a century later that the value moving the lower limbs, in consequence, as is gener- of rest in joint tuberculosis was formulated by ally supposed, of a curvature of some part of the spine. Until the curvature of the spine has been dis- covered, it generally passes for a nervous complaint.... I have in compliance with custom called the Pott’s Puffy Tumour disease a palsy... In common nervous palsy: the legs and thighs are ren- 1760 he published a monograph entitled “Obser- dered unfit for all the purposes of locomotion and do vations on the Nature and Consequences of also lose much of their sensibility, but they have neither Wounds and Contusions of the Head, Fractures of the flabby feel, which a truly paralytick limb has, nor the Skull, Concussions of the Brain, etc. His publications included abundant case which Pott dealt mainly with the morbid anatomy histories, which are interesting apart from their of disease of the spine, accompanied by engrav- main purpose; his delightful narrative touches ings illustrating the changes that occurred in the upon the occupations, social habits and customs 276 Who’s Who in Orthopedics of ordinary people in the eighteenth century. The with this degrading custom, but a centenarian still particular scalp swelling or puffy tumor that he lives who at the age of 12 worked 15 hours a day, described is referred to in this paragraph: climbed the insides of chimneys, and swept down soot with a hand brush.

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Pedro Mancias The University of Texas Medical School at Houston 25 mg unisom amex, Houston buy unisom 25mg lowest price, Texas purchase unisom 25 mg on-line, U. Maria Medical University of South Carolina, Charleston, South Carolina, U. Julia McMillan Johns Hopkins Hospital, Departments of Pediatric Neurology and Pediatric Infectious Disease, Baltimore, Maryland, U. Miner Division of Neurology, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City, U. Mink University of Rochester, Departments of Neurology, Neurobiology & Anatomy, and Pediatrics, Rochester, New York, U. Morrison Department of Neurology, University of New Mexico, Albuquerque, New Mexico, U. Moser Kennedy Krieger Institute, Johns Hopkins University, Baltimore, Maryland, U. Moxley, III Department of Neurology, University of Rochester Medical Center, Rochester, New York, U. SakkuBai Naidu Neurogenetics Unit, Kennedy Krieger Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, U. North Institute for Neuromuscular Research, Children’s Hospital at Westmead, Sydney, Australia Lori L. Olson Medical University of South Carolina, Charleston, South Carolina, U. Contributors xxv Robert Ouvrier TY Nelson Department of Neurology and Neurosurgery, Children’s Hospital at Westmead, Sydney, Australia Roger J. Packer Neuroscience and Behavioral Medicine, Division of Child Neurology, Children’s National Medical Center, The George Washington University, Washington, D. Pidcock Department of Pediatric Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland, U. Annapurna Poduri Division of Pediatric Neurology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, U. Pranzatelli National Pediatric Myoclonus Center, Department of Neurology and Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, U. April Puscavage Johns Hopkins University School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland, U. Raymond Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, U. Anthony Redmond Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, U. Tyler Reimschisel McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins Hospital, Baltimore, Maryland, U. Mark Riddle Department of Psychiatry, The Johns Hopkins Hospital, Baltimore, Maryland, U. Ryan Institute for Neuromuscular Research and Discipline of Paediatrics and Child Health, Children’s Hospital at Westmead, Sydney, Australia Shlomo Shinnar Departments of Neurology, Pediatrics, and Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, U. Siberry The Johns Hopkins Hospital, Department of Pediatrics, Baltimore, Maryland, U. Singer Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, U. Constance Smith-Hicks The Johns Hopkins Hospital, Baltimore, Maryland, U. Sumner National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, U. Tamargo Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.

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