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By V. Will. University of Georgia.

Change to making the proximal cuts boat shaped to prevent the stress risers (Fig purchase alfuzosin 10 mg visa. The graft is usually cut to this shape to pass into the joint; now it is just cut in that shape before removing it quality alfuzosin 10mg. Tendon Rupture This may occur if a very large graft is taken from a small tendon. The older literature reported a high incidence of patellofemoral pain associated with ACL recon- struction. However, most of the disability could be blamed on rehabili- tation programs that consisted of immobilization. There is no doubt that some patients will develop pain, some will develop crepitus, and some will have tendonitis, but results have improved with more aggressive rehabilitation programs with early motion and weight bearing. To prevent the patella from being bound down, the patella should be mobilized daily by the physiotherapist. Arthrofibrosis This severe problem is rarely seen now in ACL reconstructions. The true condition is idiopathic and is probably the result of fibroblastic pro- liferation. The more common condition of loss of range of motion may be the result of incorrect tunnel placement or postoperative immo- Hamstring Grafts 53 bilization. In the mid-1980s, a limited range of motion hinge cast (pre- venting 30° of extension) was used for six weeks postoperatively, thereby causing problems in regaining extension. Many of these cases required arthroscopic debridement (10–18%, in the first year). The loss of extension was almost completely eliminated by changing to an exten- sion splint. The acceptance of aggressive physiotherapy to regain exten- sion eliminated the problem. This problem of postoperative stiffness made the use of a synthetic ligament, with no immobilization, very attractive. Contraindications to Harvest of the Patellar Tendon Preexisting Patellofemoral Pain Is preexisting patellofemoral pain a contraindication to harvesting the patellar tendon? The conventional wisdom is yes; it would not be a wise procedure in this situation. In the past, when chondromalacia was seen at the time of arthroscopy, the graft choice would be changed to hamstrings. The Small Patellar Tendon The harvesting of the central third of the patellar tendon in a small tendon is more theoretical than practical. The advice in a small patient with a tendon width of only 25mm would be to take a narrower graft of 8 to 9mm or use another graft source. Preexisting Osgoode-Schlatters Disease Shelbourne has reported that a bony ossicle from Osgoode-Schlatters disease is not a contraindication to harvest of the patellar tendon. Because the fragment usually lies within the bony tunnel, this bone may be incorporated into the tendon graft. Hamstring Grafts Advantages of Hamstring Grafts The main advantage of the hamstring graft is the low incidence of harvest site morbidity. The 4-bundle graft is usually 8mm in diameter, which is a larger cross-sectional area than the patellar tendon. Graft Selection Disadvantages of Hamstring Grafts The disadvantage of any autograft is the removal of a normal tissue to reconstruct the ACL. The harvest of the semitendinosus seems to leave the patient with minimal flexion weakness. One study did show some weakness of internal rotation of the tibia after hamstring harvest. Injury to the saphenous nerve is rare and can be avoided with careful technique.

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The parallels between Moses’ Ten Commandments and Liam Donaldson’s Ten Tips for Better Health are striking—they are even more explicit in the ‘European Code Against Cancer order 10 mg alfuzosin with mastercard, or Ten Commandments’ cited in the Health of the 70 SCREENING Nation White Paper (DoH December 1999: xiv; DoH 1992:66) buy generic alfuzosin 10mg on line. Injunc-tions against certain activities—‘thou shalt not’—are a feature of both codes, but figure even more prominently in the morality of health promotion. Whereas the Mosaic code emphasised the conduct of individuals in society, the healthy lifestyle command-ments have a highly individualistic focus. As many commentators have noted, this narcissistic character of the contemporary cult of health reflects the anxieties of an increasingly atomised society. The fact, for example, that health promotion initiatives tend to be taken up more readily by the better off in society means that the advance of this agenda is likely to intensify social fragmentation rather than help to overcome it. Perhaps the greatest defect of health promotion, by contrast with traditional religion, is its lack of an inspirational element. Another version of the ten commmandments of health promotion—the American Institute of Public Medicine’s ‘Ten New Year Resolutions’ for 1992—included alongside the familiar exhortations, recommendations to ‘develop a social support network’ and to ‘have a sense of purpose’ (quoted in Rosenberg 1997). If only tackling these great social and spiritual deficits of the late twentieth century Western world were as easy as other ‘resolutions’, such as ‘avoiding second hand smoke’ and ‘limiting red meat, eggs and cheese’. Futhermore, when it comes to suffering and death, the inescapable elements of the human condition, the health promotionists fall silent. While health promotion cannot replace religion, its moralism has a corrupting effect on medicine, as the American writer HL Mencken recognised in the 1920s: The aim of medicine is surely not to make men virtuous; it is to safeguard them and rescue them from the consequences of their vices. In the late 1970s, the Labour government first took up the cause of prevention, in a series of policy initiatives which made little immediate impact, but marked a significant innovation on which future policy-makers could build. A decade later, Margaret Thatcher’s Conservative government launched what was claimed to be the biggest public health campaign in history in relation to Aids, and in the early 1990s extended its involvement in health promotion through the Health of the Nation initiative. After its election victory in 1997, New Labour appointed the first minister of public health and made the promotion of ‘healthy living’ a central theme of policy, not merely for the Department of Health, but for other government ministries. Looking at this period as a whole, the most striking features are the advance of state intervention in ‘health-related’ individual behaviour, the decline of critical responses and the absence of popular resistance. However, it is important to recognise that the process of state intervention in lifestyle advanced in fits and starts as a result of different government initiatives, driven by different concerns in different contexts and, in the early stages, with indifferent success. It is no doubt true that the reluctance of governments in the 1950s and 1960s to take action against tobacco in response to demands from medical bodies was largely attributable to fiscal and electoral considerations. Politicians at first rejected requests from anti-cholesterol campaigners to endorse their ‘healthy diet’ because of similar concerns about upsetting meat and dairy farmers, food processors and retailers—and their numerous and generally contented customers. Yet it would be a mistake to under-estimate the influence of popular traditions of suspicion of any official incursions on individual autonomy as a factor deterring state intrusion in individual behaviour, even in the cause of improving health. The greater vitality of such traditions in the USA explains the more intense controversy around these issues there compared with Britain where state intervention had become more widely accepted. However, even in Britain up to the 1960s there was some reticence among the medical elite about official intrusion into the personal domain. Thus, for example, the publication of the RCP’s 1962 report recommending a public campaign against smoking followed an internal struggle of an incoming modernising leadership against an old guard personified by Lord Russell Brain, the eminent neurol-ogist. Brain ‘doubted very much’ whether ‘going beyond the facts’ to ‘giving advice to the public as to what action they should take in the light of the facts’ should be the function of the college (Booth 1998). The first major intervention of the state in health promotion came in the form of a discussion document produced under the authority of Labour health minister David Owen in 1976, entitled Prevention and Health: Everybody’s Business (DHSS 1976). Its central theme was that ‘much of the responsibility for ensuring his own good health lies with the individual’ (DHSS 1976:95). A White Paper, published the following year, with the same title, put the same message in a hectoring tone: Much ill-health in Britain today arises from over-indulgence and unwise behaviour. The individual can do much to help himself, his family and the community by accepting more direct responsibility for his own health and well-being. When Labour came to power in 1974, the country was in the grip of the recession that marked the end of the long post-war boom and its attendant social stability. At a moment when the government was preoccupied with the growing burden of public expenditure, Owen was appointed as a junior health minister. As a former hospital doctor, Owen was undoubtedly familiar with the radical critique of conventional medicine which had emerged over the preceding decade (see Chapter 8).

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Therefore it is essential that your piece also fulfils this criterion if it is to be accepted cheap 10mg alfuzosin. Your market research must include a study of the needs and con­ 306 WRITING SKILLS IN PRACTICE cerns of your intended audience order 10mg alfuzosin with amex. You will have gained some insight about the readers by looking at the type of features in the paper or magazine. Remember that you can also build up a profile of the reader by looking at the advertisements (Dick 1996). Other clues will come from the let­ ters page or similar slots where the reader is able to contribute. The answers to these questions will tell you, amongst other things, the age range, educational level, and social and economic grouping of the readership. Find out how long the publication needs for preparing articles for pub­ lication. This is known as the lead time and will vary between magazines and newspapers. You need to be sure that you have time to write the article and prepare it for submission. At the end of your research, you will know: ° the circulation of the publication ° how often it is published ° the lead time ° the target readership ° the aims of the publication ° the type of articles ° the general approach of the publication ° the style of presentation. You will now be able to make a shortlist of magazines or papers you wish to approach. Remember that a successful submission will conform to the usual style, tone and content of the publication. Making an approach It is important to only contact one paper or magazine at a time, so start with the publication that is top of your list. This gives you time to prepare what you want to say and put forward your ideas in the best way. Although some editors are prepared to read through unsolicited manuscripts, the majority prefer authors to send a preliminary letter containing a synopsis of their proposed article. This is usually re­ ferred to as a query letter, and will save you committing time to writing the ARTICLES FOR THE MEDIA 307 whole article until you have at least a firm indication of interest. This information is sometimes given in the writing guides (listed earlier) or you may be able to find it in an issue of the publication. A query letter needs to be concise and include such details as: ° A few brief introductory details about yourself. It will give the editor an idea of the content and the style of presentation. It may be several weeks before you hear anything so be patient and definitely avoid the temptation to canvass other editors. You are likely to get one of the following responses: ° A definite acceptance. You now have the option to negotiate and rework your piece until you have a mutually acceptable idea. However, a negative response is not necessarily a sign that your proposal is at fault. I feel this practical article will fit with your magazine’s modern approach to childbirth. It provides advice on planning a home de­ livery and includes two case studies. I have previously had articles published in the Midwifes Associ­ ation Newsletter and Parentcraft Journal. Yours sincerely, Signature Name (title/qualifications) Position Figure 22. Is the idea basically sound but is it not what the editor is looking for at the present time? Has the topic already been covered, or is it not one the editor feels will interest his or her readership?

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