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Public anxieties about breast cancer were encouraged by the official campaign to raise ‘breast awareness’ order acticin visa acne during pregnancy. October 1996 was designated Breast Cancer Awareness Month and proven 30 gm acticin skin care on center, following the style set by the adoption of a red ribbon by Aids activists buy 30 gm acticin amex acne on buttocks, a pink ribbon became a badge of breast awareness. One of the main effects of the promotion of breast cancer awareness is that it generates an exaggerated sense of risk. The Cancer Research Campaign promoted the estimate that ‘1 in 12’ women will develop breast cancer, which featured on a nationwide poster campaign. According to an authoritative review, this was ‘correct only for women who have escaped a number of equally serious but more likely threats to life at an earlier age’ (Bunker et al. The authors concluded that ‘for most women, the lifetime risk of dying of breast cancer is only 1 in 26; the other 25 will die of something else’. Most of the women who come into the surgery worried about breast lumps are young, that is, under 50—though the vast majority of deaths from breast cancer are in women over 65. Only one woman in 136 in Britain dies of breast cancer before the age of 50. Though the risk of dying from breast cancer increases with age, it appears to progress more slowly in older women, so that they often live long enough to die from some other cause. One of the ironies of discussing the risks of breast cancer is that, if the woman smokes, she has a greater risk of dying from lung cancer; even if she is a non- smoker, she is far more likely to die of heart disease. Public awareness of breast cancer has intensified the demand for screening tests which promise early diagnosis. The most basic is the technique of breast self-examination, which is generally recognised to be much more effective in generating anxiety than it is at detecting tumours (Austoker 1994a). Women’s magazines and health promotion leaflets are still offering detailed diagrams and earnest advice about 61 SCREENING how to detect lumps—resulting in a steady flow of frightened women, some scarcely out of their teens, who are more likely to win the national lottery than to have breast cancer. Another consequence of greater breast cancer awareness is the demand to extend mammography to women in their 40s. According to one commentator, this has provoked a debate in the USA ‘out of proportion to its potential impact on public health’ (Wells 1998). Despite the fact that numerous trials have failed to confirm the efficacy of this technique in younger women—and despite concerns that the radiation exposure involved might do greater harm— political pressures resulting from disease awareness campaigns have resulted in younger women having mammograms. Women who have had breast cancer are perhaps the greatest casualties of breast awareness. It is not only that they are reminded of their disease every time they turn on the television or open a newspaper or magazine—and every time they see a pink ribbon on the bus or train. The popular discussion of the role of lifestyle factors in predisposing women to breast cancer compounds women’s worries about their future with guilty reflections on their past behaviour. This is encouraged by epidemiological surveys which report the loosest of associations as causal influences. Thus the risk of breast cancer appears to be increased in women who have no children or who have them after the age of 30; in women who have taken the oral contraceptive pill or hormone replacement therapy; in women who drink alcohol and have a high fat diet. The relatively strong influence of family history on chances of getting breast cancer provides further scope for recriminations about genetic destiny and fatalistic ruminations about dying a premature and disfiguring death. During breast awareness week, a patient of mine who has survived mastectomy, radiotherapy and chemotherapy and now has a good prognosis, came in to ask me what she had done to deserve breast cancer. I don’t know who benefits from breast awareness, but I know many of its victims. Carrying on screening Despite all the problems of the cervical cytology and mammography programmes, the demand for more screening tests for other cancers continues to rise.

Fasciculations may be seen in: Motor neurone disease with lower motor neurone involvement (i generic acticin 30 gm online acne laser. Fasciculations may need to be distinguish from myokymia or neuromyotonia order acticin online from canada skin care heaven coupon. Journal of the Neurological Sciences 1997; 152 (suppl1): S43-S48 Layzer RB buy cheap acticin 30 gm on-line acne cure. Muscle Nerve 1994; 17: 1243-1249 - 120 - Fatigue F Cross References Calf hypertrophy; Cramp; Fibrillation; Lower motor neurone (LMN) syndrome; Myokymia; Neuromyotonia Fast Micrographia In “fast” micrographia, written letters are microscopic from the outset, sometimes approximating to a straight line, though produced at nor- mal speed without fatigue. This pattern has been observed in progres- sive supranuclear palsy and with globus pallidus lesions, and contrasts with the “slow” micrographia, writing becoming progressively slower and smaller, seen in idiopathic Parkinson’s disease. Journal of Neurology, Neurosurgery and Psychiatry 2002; 72: 135 (abstract) Cross References Micrographia Fatigue The term fatigue may be used in different contexts to refer to both a sign and a symptom. The sign of fatigue, also known as peripheral fatigue, consists of a reduction in muscle strength with repeated muscular contraction. This most characteristically occurs in disorders of neuromuscular junction transmission (e. In myasthenia gravis, fatigue may be elicited in the extraocular muscles by prolonged upgaze caus- ing eyelid drooping; in bulbar muscles by prolonged counting or speech causing hypophonia; and in limb muscles by repeated contrac- tion, especially of proximal muscles (e. Fatigue in myasthenia gravis is understood as a decline in the amount of acetylcholine released from motor nerve terminals with successive neural impulses, along with a reduced number of functional acetylcholine receptors (AChR) at the motor end-plates, due to binding of AChR antibodies and/or comple- ment mediated destruction of the postsynaptic folds. This may occur in multiple sclerosis (MS), post-polio syndrome, post-stroke syndromes, and chronic fatigue syndrome (CFS). In MS and CFS, fatigue may be a prominent and disabling complaint even though neurological examination reveals little or no clinical deficit. This type of fatigue is ill-understood: in MS, frequency- - 121 - F Femoral Stretch Test dependent conduction block in demyelinated axons has been sug- gested, as has hypothalamic pathology. Current treatment is sympto- matic (amantadine, modafinil, 3,4-diaminopyridine) and rehabilitative (graded exercise). Fatigue may be evaluated with various instruments, such as the Krupp Fatigue Severity Score. Drugs 2004; 64: 1295-1304 Cross References Dystonia; Hypokinesia; Hypometria; Micrographia; Weakness Femoral Stretch Test The femoral stretch test, or reverse straight leg raising, consists of extension of the hip with the knee straight with the patient lying prone, a maneuver which puts traction on the femoral nerve or L3 root and may exacerbate pain in a femoral neuropathy or L3 radiculopathy, perhaps due to a retroperitoneal hemorrhage. Cross References Lasègue’s sign Fencer’s Posture, Fencing Posture Epileptic seizures arising in or involving the supplementary motor area may lead to adversial head and eye deviation, abduction and external rotation of the contralateral arm, flexion at the elbows, and posturing of the legs, with maintained consciousness, a phenomenon christened by Penfield the “fencing posture” because of its resemblance to the en garde position. To avoid falling and to maintain balance the patient must “chase”the cen- tre of gravity, leading to an increasing speed of gait and a tendency to fall forward when walking (propulsion). A similar phenomenon may be observed if the patient is pulled backward (retropulsion). Festination is common in idiopathic Parkinson’s disease; it is asso- ciated with longer duration of disease and higher Hoehn & Yahr stage. Festination may be related to the flexed posture and impaired postural reflexes commonly seen in these patients. It is less common in sympto- matic causes of parkinsonism, but has been reported, for example in aqueduct stenosis. Festination as the lead- ing symptom of late onset idiopathic aqueduct stenosis. Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 599-600 Cross References Freezing; Parkinsonism; Postural reflexes Fibrillation Fibrillation was previously synonymous with fasciculation, but the term is now reserved for the spontaneous contraction of a single muscle fibre, or a group of fibers smaller than a motor unit, hence this is more appropriately regarded as an electrophysiological sign without clinical correlate.

Apart from their appeal as gemstones generic 30gm acticin mastercard skin care brand owned by procter and gamble, diamonds possess a remarkable 75 76 P buy cheap acticin 30 gm on line skin care must haves. Some of the outstanding properties of diamond • Hardest known material giving extreme wear resistance • Highest bulk modulus discount acticin line skin care wiki, i. Indeed, a glance at any compendium of material data properties will prove that diamond is almost always ‘the biggest and best’. Amongst other properties, diamond is the hardest known material, has the highest thermal conductivity at room temperature, is transparent over a very wide wavelength range, is the stiffest material, the least compressible, and is inert to most chemical reagents. With such a wide range of excep- tional properties, it is not surprising that diamond has sometimes been referred to as ‘the ultimate engineering material’. Unfortunately, it has proved very difficult to exploit these properties, due both to the cost and scarcity of large natural diamonds, and the fact that diamond was only available in the form of stones or grit. It had been known for 200 years that diamond is composed solely of carbon, and many attempts were made to synthesise diamond artificially using as a starting material another commonly occurring form of carbon, graphite. This proved extremely difficult, mainly because at room temperature and pres- sure, graphite is more stable than diamond. Although the difference in stability between the two forms of carbon is actually quite small, their structures are so different that it would require a large amount of energy to convert between them. Ironically, this large energy barrier which makes diamond so rare is also responsible for its existence, since diamond, once Diamond thin films 77 formed, cannot spontaneously convert to the more stable graphite phase. To overcome these problems, researchers realised that in order to form diamond, they had to choose conditions where diamond, and not graphite, is the more stable phase. The knowledge of the conditions under which natural diamond is formed deep underground, suggested that diamond could be formed by heating carbon under extreme pressure. This process forms the basis of the so-called high-pressure high-temperature growth technique, first marketed by General Electric, and which has been used to produce ‘industrial diamond’ for several decades. In this process, graphite is compressed in a hydraulic press to tens of thousands of atmospheres, heated to over 2000°C in the presence of a suitable metal catalyst, and left until diamond crystallises. The diamond crystals this produces are used for a wide range of industrial processes which utilise the hardness and wear resistance properties of diamond, such as cutting and machining mechan- ical components, and for polishing and grinding of optics. However, the drawback of this method is that it still produces diamond in the form of single crystals ranging in size from nanometres to millimetres, and this limits the range of applications for which it can be used. What is required is a method to produce diamond in a form which can allow many more of its superlative properties to be exploited – in other words, diamond in the form of a thin film. These ideas led to experiments in which carbon-containing gases were heated under reduced pressure until the molecules broke apart, and then these fragments were condensed onto a nearby surface. Analysis showed that the thin film that resulted from this did, indeed, contain diamond. However, the rate of growth in these early experiments was low, and the films were impure, containing a large proportion of unwanted graphite. The breakthrough came in the late 1960s, when researchers in the USA discovered that the presence of atomic hydrogen during the deposi- tion process would remove graphite from a surface much faster than diamond. In diamond, every carbon atom is bonded to four others in a strong, rigid tetrahedral structure. This process became known as ‘chemical vapour deposition’ (CVD), since it involves a chemi- cal reaction occurring within a vapour over a surface, leading to deposition of a thin coating onto that surface. Over the next few years more break- throughs were made which allowed diamond films to be grown at signifi- cant rates on many useful materials. This series of discoveries stimulated world-wide interest in diamond CVD, in both academia and industry, which continues to the present day. While each method differs in detail, they all share a number of features in common.

As the patient progresses through the rehabilitation phase generic acticin 30gm with mastercard skin care hospitals in hyderabad, the nurse’s role becomes more supportive and educative order acticin 30 gm otc acne 17 year old male, with the patient taking responsibility through self-care or by directing carers buy discount acticin 30 gm online acne 7 months postpartum. Choice of bed The standard King’s Fund bed, or profiling bed, with a stable mattress consisting of layers of varying density foam, is suitable for most patients, with the addition of a Balkan beam and spreader bar. It is probably the best bed for tetraplegics requiring skull traction, facilitating good positioning of the shoulders and arms. An electrically powered turning and tilting bed is particularly suitable for heavy patients, and those with multiple injuries. It permits easier nursing as far as numbers are concerned, but still requires a full team of five or four nurses for inspection of pressure points, especially the natal cleft, for hygiene requirements, and bowel management. Skin inspection for red marks, spinal alignment and positioning of limbs is essential for a patient • Support injured spine in alignment with spinal cord injury. The aims are simple: to support the • Maintain limbs and joints in functional position injured spine in a good healing position; to maintain limbs and • Passive movements joints in a functional position, thus avoiding deformity and contractures, and to reduce the incidence of spasticity. There are several ways of achieving these aims, so the methods chosen should follow discussion with the interdisciplinary team, and suit the patient, level of injury, and the availability, knowledge and skill of the nursing staff. Spinal alignment Before undertaking a turn or preparing to move/transfer a patient, spinal alignment should be maintained by checking (when the patient is supine) that the nose, sternum and symphysis pubis are in alignment and that the shoulders and hips are level. Handling and turning Patient handling techniques need to be considered in relation to the Manual Handling Operations Regulations 1992. Patients with spinal cord injury are unable to help, and care must be taken to maintain alignment and stability of the neck and back at all times throughout the handling technique. This may pose problems for the staff when considering the method of transfer and movement of a patient, hence the need for rigorous assessment with the application of ergonomic principles. Manual hoisting aids with stretcher attachments, and side to side, and up and down transfer products are available in the United Kingdom. Outside the European Community, and especially in developing countries, handling equipment may not be available, and there may be no alternatives following risk assessment but to handle the patient manually. When transferring or moving a patient with an acute cervical injury, to maintain neck alignment and stability, the Figure 8. The nurse at the patient’s head takes control and coordinates the turn after checking her team is ready. Countertraction, starting at the top of the patient, may also be used to prevent movement of the spine when inserting hands or equipment under the patient, or starting at the foot end first when hands are being withdrawn (Figure 8. A log roll is needed for carrying out nursing care, such as bowel management, skin hygiene, and for lateral positioning of both paraplegic and tetraplegic patients. When the log roll is complete, the patient remains supported by pillows (Figure 8. Note the alignment of the shoulders, hip, iliac crest, and upper leg in Figure 8. End positioning of the head will be determined by the mechanism of injury and the head and neck will be maintained in a neutral, extended, or flexed position, Figure 8. The pelvic twist The pelvic twist is a simple turn needing only three nurses to perform and suitable for many tetraplegic patients. The nurse at the patient’s head holds the shoulders securely to the bed; the second nurse (standing on the side to which the patient is being turned), applies countertraction and gets ready to support the back and legs on completion of the twist, before inserting the pillows. The third nurse proceeds with the twist by placing her or his upper arm under the patient’s back (using countertraction), and her or his lower arm under the patient’s nearest thigh, and over the furthest thigh to support and move Figure 8. The movement is a gentle lift and turn of the near hip joint, enough to free the sacrum of any pressure (Figure 8. On completion of the turn, a pillow is folded in half into the lumbar region to support the back and pelvis, and two pillows are placed under the upper leg (Figures 8. In all turns involving tetraplegic patients, the nurse holding the head is in charge of the timing and coordination of the team.

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