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Acupuncture is based on the Chinese concept of balanced Qi (pronounced chee) discount diabecon 60caps without a prescription, or vital energy discount diabecon 60caps mastercard, that flows throughout the body via 12 main and 8 secondary pathways (called meridians) 60caps diabecon for sale, accessed through the more than 2000 acupuncture points on 54 thefacts AS-07(51-60) 5/29/02 5:49 PM Page 55 Nontraditional (complementary, or alternative) therapy the human body. It is one of the oldest medical pro- cedures in the world, originating in China more than 2000 years ago. It is believed to remove the imbalances of Yin (negative energy and forces in the universe and human body) and Yang (posi- tive energy). This brings the body into balance, keeps the normal flow of the vital energy Qi unblocked, and restores health to the mind and body. Acupuncture became widely known in the US in 1971 when New York Times reporter James Reston wrote about how doctors in China eased his abdom- inal pain after surgery by puncturing the skin with hair-thin needles at particular locations. Although the mechanism of action is unclear, stimulation of acupuncture points may lead to release by the brain and spinal cord (via the endorphin system) of opium-like molecules (neurotransmitters and neu- rohormones), that help to modulate pain; the same can happen also after vigorous exercise. It has been shown that a real drug, naloxone (which inhibits endorphin-producing cells in the brain), can reverse pain relief obtained by placebo (sham) painkiller; this indicates that in some cases placebo works via the endorphin system. The Chinese claim that acupuncture also leads to biochemical changes that may stimulate healing and promote general well-being. The World Health Organization (WHO), which is the health branch of the United Nations, lists more than 40 conditions for which acupuncture is used, including nonspecific back and neck pain, and arthritis. This is based on mostly anecdotal evi- thefacts 55 AS-07(51-60) 5/29/02 5:49 PM Page 56 Ankylosing spondylitis: the facts dence, mostly from people who report their own suc- cessful use of the treatment. Scientific studies are under way to establish the validity of this anecdotal evidence of the potential benefit of acupuncture in some forms of arthritis (see NIH, 1998). Other therapies Hypnosis can also be used to promote relaxation and help you cope better with pain. Another way of achieving a restful and relaxed state is by guided imagery, which involves creating a vivid and pleasant mental picture. For example, you might see yourself sitting on a beach on a warm day, looking at the waves and hearing them pounding on the shore. A related method called bio-feedback involves using various machines that monitor one’s body temperature, heart rate, breathing patterns, and other bodily functions, and provide feedback that helps you to learn how to produce these effects and a feeling of relaxation voluntarily, without the need for machine monitors. Holistic medicine deals with an integrated com- prehensive overview of a physical, mental, emo- tional, and spiritual being; practitioners may suggest therapies based on the whole person, including spir- itual and mental aspects, not just the specific part of the body being treated. They may advise changes in diet, lifestyle, and physical activity to help treat your condition. Transcutaneous electrical nerve stimulation (TENS) requires passing an electric current to nerve cells through electrodes placed on the skin. This treatment is potentially dangerous for about 10% of the population who have mild, severe, or even fatal allergic reactions to insect venom. Snake venom is toxic and there is little scientific support for its use in treating arthritis. Ayurveda, the traditional Indian system of medi- cine, is also not effective in AS.

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When young patients suffer from frank dislocations of the patella buy generic diabecon 60 caps on-line, surgery should be considered discount diabecon 60 caps without prescription. From my many years of treating these types of patients cheap 60 caps diabecon visa, I recommend that the patients undergo an arthroscopy before any attempts to treat the instability begin. The reason is that I have seen so many cases with normal X-rays that have 10-15 loose bodies in their knees. If these pieces consist of just cartilage, they cannot be seen on X-ray. When a dislocated patella jumps back, it often hits the lateral femoral condyle with considerable force. Small cartilage pieces are blasted away as well from femur as from the patella. If they are overlooked they will eventually lead to blockings of the knee in the future. The role of the medial patello-femoral ligament can also not be overstressed. When I was taught to operate on these cases, this ligament was not even known. I also feel that when patellar instability is going to be operated on, it is extremely important that the surgeon carefully controls in what direction the instability takes place. If someone performs a routine lateral release in a case of medial instability, he will end up vii viii Foreword having to repair the lateral retinaculum in order to treat the medial dislocation that eventually occurs. Hughston and also Teitge have warned against this in the past. It is a pleasure for me to recommend this excellent textbook by Dr. Ejnar Eriksson, MD, PhD Professor Emeritus of Sports Medicine Karolinska Institute, Stockholm, Sweden Preface This book reflects my deep interest in the pathology of the knee, particularly that of the extensor mechanism, and to bring to the fore the great importance I give to the concept of subspecialization, this being the only way to confront the deterioration and medioc- rity of our speciality, Orthopaedic Surgery; and to provide our patients with better care. In line with the concept of subspecialization, this book necessarily required the partici- pation of various authors. In spite of this, I do not think there is a lack of cohesion between the chapters. Now, there are certain variations in form, but not in basic content, regarding some topics dealt with by different authors. It is thus evident that a few aspects remain unclear, and the controversy continues.

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The Eye 53 Box 4-1 Examples of Drugs with Oculotoxic Effects Amiodarone Gold salts Anticholinergic agents Hydroxychloroquine Antihistamines Isoniazid Chloramphenicol Phenothiazines Chloroquine Quinine Contraceptives (oral) Rifampin Corticosteroids Sympathomimetics Digitalis Tamoxifen Ethambutol tive equipment buy discount diabecon 60caps on line. If the patient wears contact lenses diabecon 60caps cheap, determine how long the lenses are worn and when they are changed buy diabecon 60 caps amex, as well as how they are cleansed and stored between wearings. PHYSICAL EXAMINATION Order of the Examination The eye examination begins with determination of the patient’s visual acuity. Next, it is typical for the examiner to inspect the external and accessory structures and then move inward to include the eye. Inspection is the primary technique used in the eye exam. However, when a mass or lesion is discovered, palpation of the area is indicated. If the patient has complained of discharge, palpation of the punctum, lids overlying meibomian glands, and in the region of the medial canthus may express the discharge. The globe also can be palpated gently to determine tone. If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute angle glau- coma is present because dilating the eye may increase the intraocular pressure. Visual Acuity Visual acuity should, at a minimum, be measured, with the patient’s corrective lenses in place, if corrective lenses are used, and in a well-lighted area. Testing the visual acuity assesses a patient’s central vision and should be performed one eye at a time and then with both eyes simultaneously. Visual acuity is typically assessed with a Snellen chart, with the patient standing 20 feet from the chart. There are times when the patient cannot read even the top line of the Snellen chart from 20 feet. In this case, you may have the patient move progressively closer to the chart and record the distance at which the top line can be read, if needed. If the patient cannot read the chart at a near distance, record whether the patient can count fingers, identify gross hand motion, or detect light. Near vision is tested using a hand-held chart, such as a Rosenbaum chart, typically held 14 inches from the eyes. Color vision can be grossly tested using the color strips (green and red) on the Snellen chart or by asking the patient to identify the colors of other objects. Ishihara plates can be used for a more thorough assessment of color vision. Carefully identify the location of any visual defects. Alternatively, peripheral vision can be measured much more objectively using equipment designed specifically for this purpose. Alignment Observe the position of the eyes as the patient follows an object as it is moved smoothly through the six cardinal positions, approximately 12 inches in front of the face.

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