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By Z. Ayitos. Philander Smith College.

He was giant of a man generic nolvadex 10 mg free shipping, tall purchase 10 mg nolvadex with mastercard, broad shouldered purchase nolvadex 10mg with amex, undoubt- one of the very few British surgeons to be a per- edly handsome and always elegant; even as a sonal friend of Professor Pauwels and one of only schoolboy he doubtless had an imposing style discount nolvadex 20 mg with mastercard. Thomas’, that was it and the Dean, poor wrote only in “High German” so, in his early man, was probably not given an option to refuse. It is a tribute to his his early admission, winning the Cheselden remarkable intelligence that it took only 3 months Medal for Surgery. As was possible in those days, of early-morning daily German lessons for him to he passed his primary before he qualified in 1931. It seems unlikely his friend, Paul Maquet, one of Pauwels’ disciples he ever actually applied for a job; certainly he and the pioneer of the understanding of the never seems to have attended an interview. He leg alignment in knee surgery, he was translating was appointed a house surgeon to Sir Max Page, the works of Pauwels, Braun and Fischer into a fine clinician who clearly had a tremendous English. He appointed himself sold well in Germany, as the text was more com- to his next post, informing Rowley Bristow at a prehensible when written in English than in the garden party that he proposed to come and work complexity of classical German! Bristow was the first orthopedic consult- 1960, I can recall the often animated debates on ant at St. Thomas’ and had been placed there by biomechanics that would take place among his mentor, Sir Robert Jones. Even though the Messrs Furlong, Maquet, Kummer, the distin- First World War had given a great boost to ortho- guished anatomist and pioneer of comparative pedic and trauma surgery, the specialty was, in the biomechanics from Cologne, and Bombelli, the 1930s, still tiny. Such expansion that had occurred Italian guru of proximal femoral osteotomy. Finally, it was the link with the From the former Furlong learned the art of clini- German faciomaxillary surgeon Dr. Osborn that cal surgery and, from the latter, the art of leader- would introduce hydroxyapatite coatings and ship. He duly became registrar and then chief revolutionize prosthetic fixation. Furlong’s career was extraordinary in the true The medical world of the 1930s was very dif- sense of the word, for nothing about him or what ferent from today. To start with, it was narily long hours but the pace of life was far less long, very long; indeed, it probably qualifies for frenetic. Will orthopedic in the surgeons’ room in classical Furlong style: surgery or, indeed, any branch of medicine, “The biggest inconvenience in the life of a Harley encounter again a doctor who spends 70 years in Street surgeon was that the dining room also acted active practice? As with most aspects of this as the patients’ waiting room so that lunch, by remarkable life, his medical career started with a necessity, had to finish by ten minutes to two. Born in 1909, he grew up in south those pre-antibiotic days, long-stay patients were London, being educated at Eltham College. At the lodged in a country hospital and there were age of 16 there was, it seems, a sharp disagree- several of these around London, for example ment between Furlong senior and the house Stanmore, Black Notley, Royal Sea Bathing master, who had taken exception to finding young at Margate and Lord Mayor Treloar’s at Alton. Furlong with his feet up on the mantelpiece while On Fridays, the “great man” from Harley some prospective parents were being shown Street/Teaching Hospital would come down in his round the school. Consequently, one week Rolls Royce, do his ward round, then operate on Furlong junior was a schoolboy and the next, Saturday morning. Sir Reginald Watson-Jones of 108 Who’s Who in Orthopedics the London Hospital went as far as Oswestry. Perkins hospital was the Church of England Home for thrust his hand into his mackintosh pocket, took Waifs and Strays at Pyrford, later renamed the out a large wad of pound notes, thrust them into Rowley Bristow Hospital. Furlong’s formative years were therefore spent He was, I understand, meant to come back as an between St. Thomas’ and Pyrford and periods out expert in spinal fusion and scoliosis, but spinal “on loan” to other friends. He was acclaimed for his surgeon to watch and much of the polish came via excellent monograph on hand injuries, published Sir Harold.

Other countries in Europe and brain buy nolvadex 20 mg amex, and in a changed texture of the brain tissue buy nolvadex 10mg on line. The brain Asia have reported BSE cheap nolvadex 10mg fast delivery, but in far fewer numbers than in tissue quality nolvadex 10 mg, particularly in the cortex and cerebellum, becomes Britain. No cases have been detected in the United States (the filled with large open spaces (vacuoles) and becomes spongy U. The “spongiform” part of BSE comes from this tex- rigorous surveillance program). The cause of BSE and CJD, near-exclusivity has yet to be conclusively determined, the 89 BSE and CJD: Ethical issues and socio-economic impact WORLD OF MICROBIOLOGY AND IMMUNOLOGY 2001 outbreak of hoof and mouth disease in the United ecule of the transmissible agent. The prototypical prion dis- Kingdom revealed that a common practice has been to feed ease of animals is scrapie, which has been long recognized in cattle “offal,” the ground up waste from the slaughter process. Following 1988, BSE has given rise to considerable infected tissue is a means of spreading the disease. The exact origin of the demic in 1993, approximately 700 cattle were newly affected prions is not known. The epidemic has been linked to changes in the Until the 1900s, scientists believed that the transmission rendering of sheep or cattle carcasses for use as protein sup- of the BSE agent to humans did not occur. However, several plements to feed-meal, suggesting that inadequately inacti- studies conducted in the latter years of the 1990s has cast vated scrapie agent from sheep, cattle or both was the initial doubt on this assumption. Following a legislation banning the feeding of ruminant brain injuries caused in BSE and CJD are identical. It these brain alterations occurred in mice injected with either is still uncertain whether the origins of BSE lie in a mutant brain tissue from BSE-diseased cattle, which was expected, or form of scrapie or if it developed naturally in cattle. Thus, development of CJD could be due to human kuru, Gerstmann-Sträussler-Scheinker (GSS) syndrome and consumption of BSE-diseased meat. These diseases are rare and, until The currently held view is that prions from cattle recently, were not considered of any great socio-economic sig- infected with BSE are capable of infecting humans and caus- nificance. For instance, younger people can be The infectivity of prion diseases appears to reside in the prion infected, and the neurological symptoms differ. PrPSc is the abnormal, protease- The existence of a vCJD is based mainly on epidemio- resistant isoform of a normal cellular membrane protein des- logical evidence. Prusiner of the University of species barrier for the transmission of BSE and CJD does not California at San Francisco has long contended that changes in exist. However, the possibility still remains that the contami- conformation underlie the dramatic differences in the proper- nating agent in the meat is really a prion that causes normally ties of the two isoforms; by abnormal molecular folding, CJD, and that this prion is naturally present in cattle but has PrPSc acquires protease resistance and a “catalytic” ability to escaped detection until now. If so, then BSE and CJD infec- recruit more conformational copies of itself from PrPC. PrPSc tions could indeed be confined to non-human and human is remarkably resistant to many procedures that inactivate conventional infectious agents and, therefore, problems have mammals, respectively. Although 90% of prion disease cases CJD disease, ethical issues and socio-economic impact; Latent arise sporadically and a further 10% arise where the family has viruses and diseases some history of the disease, it is an unfortunate fact that about eighty cases of CJD have arisen iatrogenically, that is, as a result of exposure to medical treatment, facilities, or person- nel. Cases of transmission by corneal transplant, transplant of BSE AND CJD: ETHICAL ISSUES AND dura mater, exposure to infected neurosurgical instruments SOCIOBSE and CJD: Ethical issues and socio-economic impact-ECONOMIC IMPACT and electroencephalogram probes, and transplantation of human growth hormone have been confirmed. The outbreak of bovine spongiform encephalopathy (BSE) or The indestructibility of prions creates real problems in “mad cow disease” in the United Kingdom and continental sterilizing surgical instruments; it is basically impossible, and Europe continues to concern beef and dairy producers and the equipment has retained infectivity and caused infection in general public in the United States. This concern has increased patients even after repeated “sterilizations. Neurosurgical equipment is already disposed of that has appeared in people, mostly in the U. Since vCJD is carried heavily by the lym- ease known as variant Creutzfeldt-Jakob disease (vCJD) phoreticular (blood/lymph) systems, the tonsils, appendix, and appears to be more closely related to BSE in its pathology than most recently, the lymph nodes of vCJD patients have been to traditional CJD. It is therefore assumed that vCJD has found to be full of prions, unlike in patients with classical CJD. There is concern that these lenses could the next infectious disease epidemic which may be contracted spread iatrogenic vCJD. In view of the theoretical been banned in the UK, only the “air puff” method is allowed risk of blood-borne transmission of CJD, some experts recom- now. And, of course, ophthalmological surgery could be a mend that the following groups of people not donate blood: all prime candidate for this as well.

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If necessary nolvadex 20 mg low price, a rubber device or bite may be worn in the mouth to protect the teeth order 10 mg nolvadex with amex. Psychological Bulletin 1977; 84: 767-781 Cross References Encephalopathy; Masseter hypertrophy Buccofacial Dyspraxia - see OROFACIAL DYSPRAXIA Bulbar Palsy Bulbar palsy is weakness of bulbar musculature of lower motor neu- rone origin nolvadex 10mg amex. This may be differentiated clinically from bulbar weakness of upper motor neurone origin (pseudobulbar palsy) purchase 10 mg nolvadex otc. Clinical features of bulbar palsy include: Dysarthria of flaccid/nasal type Dysphonia Dysphagia, often with nasal regurgitation Weak (“bovine”) cough; risk of aspiration +/− Wasted, fasciculating tongue +/− absent jaw jerk +/− absent gag reflex. Recognized causes include: ● Brainstem disorders affecting cranial nerve motor nuclei (intrin- sic): motor neurone disease (which may also cause a pseudobul- bar palsy) poliomyelitis glioma syringobulbia - 62 - Butt-First Maneuver B ● Cranial nerve lesions outside the brainstem (there may be associ- ated sensory signs): Infiltration by carcinoma, granuloma ● Neuromuscular junction transmission defect: myasthenia gravis. A myogenic bulbar palsy may be seen in oculopharyngeal muscular dystrophy, inclusion body myositis, or polymyositis. Cross References Bovine cough; Dysarthria; Dysphagia; Dysphonia; Fasciculation; Gag reflex; Jaw jerk; Lower motor neurone (LMN) syndrome; Pseudobulbar palsy; Upper motor neurone (UMN) syndrome Bulbocavernosus Reflex A test of the integrity of the S2, S3 and S4 spinal roots, looking for contraction of the anal sphincter (may be felt with a gloved finger in the rectum) when squeezing the glans penis or clitoris. Cross References Cauda equina syndrome; Reflexes Buphthalmos Buphthalmos, or ox-eye, consists of a large and bulging eye caused by raised intraocular pressure due to congenital or secondary glaucoma. Cacosmia - see PAROSMIA Calf Hypertrophy Calf enlargement has many causes; it may reflect true hypertrophy (enlargement of muscle fibers) or, more commonly, pseudohypertro- phy, due to infiltration with tissue elements other than muscle. Hypertrophy may be due to neuromuscular disorders producing: ● Chronic partial denervation, for example: radiculopathy peripheral neuropathy spinal muscular atrophy following paralytic poliomyelitis. Pseudohypertrophy may be due to: ● Dystrophinopathies (Duchenne muscular dystrophy, Becker dys- trophy), due to excess connective tissue. Journal of Neurology, Neurosurgery and Psychiatry 2004; 75: 1606 Wilson H, Kidd D, Howard RS, Williams AJ, Spencer GT. Postgraduate Medical Journal 2000; 76: 179-181 Cross References Gowers’ sign; Muscle hypertrophy; Myokymia; Myotonia; Neuro- myotonia Caloric Testing Caloric tests examine the vestibulo-ocular reflexes (VOR). They are mainly used in two circumstances: to identify vestibular pathology in the assessment of dizziness/vertigo when clinical tests of VOR are unhelpful and to assess brainstem integrity in coma. Each labyrinth may be sepa- rately assessed by irrigating each outer ear. Head flexion to 30˚ above the - 64 - Camptocormia C horizontal allows maximum stimulation of the horizontal semicircular canals, whereas 60˚ below horizontal maximally stimulates the lateral semicircular canals. Induced nystagmus is then timed both with and without visual fixation (in the dark, Frenzel glasses). Normally, the eyes show conjugate deviation toward the ear irri- gated with cold water, with corrective nystagmus in the opposite direction; with warm water the opposite pattern is seen. A reduced duration of induced nystag- mus is seen with canal paresis; enhancement of the nystagmus with removal of visual fixation suggests this is peripheral in origin (labyrinthine, vestibulocochlear nerve), whereas no enhancement suggests a central lesion. In coma the deviation may be present but without corrective sac- cades, even at a time when the oculocephalic responses elicited by the doll’s head maneuver are lost. As coma deepens even the caloric reflexes are lost as brainstem involvement progresses. London: BMJ Publishing, 1997: 283-314 Cross References Coma; Nystagmus; Oculocephalic response; Vertigo; Vestibulo-ocular reflexes Camptocormia Camptocormia, or “bent spine syndrome,”was first described as a psy- chiatric phenomenon in men facing armed conflict (a “war neurosis”). It has subsequently been realized that reducible lumbar kyphosis may also result from neurological disorders, including muscle disease (par- avertebral myopathy, nemaline myopathy), Parkinson’s disease, dysto- nia, motor neurone disease, and, possibly, as a paraneoplastic phenomenon. Cases with associated lenticular (putaminal) lesions have also been described. Camptocormia (bent spine) in patients with Parkinson’s disease: char- acterization and possible pathogenesis of an unusual phenomenon. Dropped head syndrome and bent spine syndrome: two separate entities or different manifestations of axial myopathy? Journal of Neurology, Neurosurgery and Psychiatry 1998; 65: 258-259 Cross References Dropped head syndrome; Dystonia - 65 - C Camptodactyly Camptodactyly Camptodactyly, literally “bent finger,” is a flexion deformity at the proximal interphalangeal joint, especially affecting the little fingers. A distinction is sometimes drawn between camptodactyly and stre- blodactyly: in the latter, several fingers are affected by flexion con- tractures (streblo = twisted, crooked), but it is not clear whether the two conditions overlap or are separate.

For a variety of genetic mixing buy 20 mg nolvadex with mastercard, called recombinant buy nolvadex 10 mg with mastercard, is the crux reasons buy discount nolvadex 20mg on line, not all scientifically based buy generic nolvadex 10 mg on-line, some people argue that of transgenics. The organisms that are created from mixing transgenic food is a consumer safety issue because not all of genes from different sources are transgenic. The glow-in-the- the effects of transgenic foods have been fully explored. Cell cycle (eukaryotic), genetic regulation of; Cell One of the major obstacles in the creation of transgenic cycle (prokaryotic), genetic regulation of; Chromosomes, organisms is the problem of physically transferring DNA from eukaryotic; Chromosomes, prokaryotic; DNA (Deoxyribo- one organism or cell into another. It was observed early on that nucleic acid); DNA hybridization; Molecular biology and bacteria resistant to transferred the resistance char- molecular genetics acteristic to other nearby bacterial cells that were not previ- ously resistant. It was eventually discovered that the resistant bacterial cells were actually exchanging plasmid DNA carry- ing resistance genes. In this way, susceptible bacterial cells Translation is the process in which genetic information, car- were transformed into resistant cells. Although there are some important differences characteristics to new cells when they reproduce because between translation in and translation in eukaryotic copies of the foreign transgenes are replicated during cell divi- cells the overall process is similar. Transformation can be either naturally occurring or the of translational control mechanisms that exist in eukaryotic result of transgenics. A molecule known as the ribosome is the site of the Certain chemicals make transgenic cells more willing to take-. The ribosome is protein bound to a second up genetically engineered plasmids. Several process where cells are induced by an electric current to take may attach to a single mRNA molecule, so that up pieces of foreign DNA. Transgenes are also introduced via many polypeptide chains are synthesized from the same engineered. The ribosome binds to a very specific region of the that infect bacterial cells are used to inject the foreign pieces mRNA called the promoter region. DNA can also be transferred using microinjection, of the sequence that will be translated into protein. A new technique to introduce transgenes into cells uses the amino acid sequence of a protein by adaptor molecules liposomes. Liposomes are microscopic spheres filled with composed of a third type of RNA known as transfer RNAs DNA that fuse to cells. There are many different species of tRNAs, with they deliver the transgenes to the new cell. In pro- composed of lipids very similar to the lipids that make up cell tein synthesis, the nucleotide sequence on the mRNA does not membranes, which gives them the ability to fuse with cells. Complementary tRNAs match up on the now use transgenics to accomplish the same results as selec- strand of mRNA every three bases and add an amino acid onto tive breeding. The three base sequence on the By recombining genes, bacteria that metabolize petro- mRNA are known as “codons,” while the complementary leum products are created to clean-up the environment, antibi- sequence on the tRNA are the “anti-codons. When the small subunit encounters the genic plants, food crops have enhanced productivity. There are Transgenic corn, wheat, and soy with herbicide resistance, for two sites in the large subunit, an “A” site, and a “P” site. The example, are able to grow in areas treated with herbicide that start signal for translation is the codon ATG that codes for kills weeds. A tRNA charged with methionine binds to the colorful tomatoes in greater abundance. After the first tRNA bearing the amino used to create immunizations and other vaccines. The Human Genome Project is a large sponding to the codon of the mRNA enters the “A” site. For example, in the family Picornaviridae there Other viruses only have a single strand of DNA. An are five genera: enterovirus, cardiovirus, rhinovirus, example is the Parvoviruses. The names of the genera typically replicate their DNA in the host’s nucleus. The replication derive from the preferred location of the virus in the body (for involves the formation of what is termed a negative-sense strand those viral genera that infect humans).

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