Among the failed 5 cases order citalopram 10 mg visa, 3 cases failed because of severe pain related to further collapse of the head effective citalopram 20 mg, 1 case failed because of a pathologic sub- capital fracture citalopram 20 mg, and 1 case failed due to ﬁxation failure. Among the surviving 77 cases, the average HHS was 72 points (61–84) preoperatively and improved to 91 points (69–100) at last follow-up. Excellent results were obtained in 47 hips, good in 22, fair in 5, and poor in 3. The 3 hips with a poor result were the result of inadequate blood supply to the femoral head. Including the 3 cases that were classiﬁed as poor, the overall clinical survival rate was 90%. All Ficat stage II, 52 (96%) of 55 stage III, and 8 (62%) of 13 stage IV had no pro- gression of osteonecrosis. The overall radiologic success rate was 90%; 28 (93%) of 30 patients with alcoholic abuse and 23 (88%) of 26 patients who had used steroids were prevented from progression. The ﬁve THAs that were treated previously by modiﬁed transtrochanteric rota- tional osteotomy combined with muscle-pedicle-bone graft were classiﬁed as Ficat stage IV initially. There was no need to revise to hip replacement in 16 cases in which modiﬁed transtrochanteric rotational osteotomy alone was performed and in 7 bone grafting cases. The complications were varus angulation in two cases, sensory disturbance on the lateral thigh in two cases, osteophyte formation in ﬁve cases, and deep vein throm- bosis in one case. In the two cases with varus angulation, postoperatively measured neck–shaft angle was 118°, but no additional treatment was required. Two cases had lateral thigh paresthesia resulting from lateral femoral cuta- neous nerve injury, but their condition improved as time passed. Five cases had shown subcapital osteophyte formation on radiography but were free of pain and had little limitation of motion. One patient had heterotopic ossiﬁcation with mild limita- tion of motion, and no further treatment was done. Deep vein thrombosis occurred in one patient, who improved after medical management.
A key influence on Owen was the innovative policy document produced by Canadian health minister Marc Lalonde in 1974 generic citalopram 40mg with amex, which recommended the pursuit of ‘healthy public policies’ by all government departments in support of the promotion of health (Lalonde 1974) cheap 20mg citalopram mastercard. While he recognised that ‘government interference in all these areas raises sensitive issues relating to individual freedom’—a concern conspicuously lacking in more recent health promotion policy—Owen attempted to shift some of the responsibility 40mg citalopram amex, and cost, of health from the state onto the individual (Owen 1976). In the inauspicious circumstances of the late 1970s, Owen’s preventive strategy made little impact. He was an unpopular minister in an unpopular government: the wave of trade union militancy provoked by its wage controls and cuts in public expenditure culminated in the notorious ‘winter of discontent’ in 1978–79, which led directly to the election of Margaret Thatcher’s first government in May 1979. As a result of a series of disputes over pay and private patients, the government had poor relations with the medical profession and, as an ambitious right-winger, Owen was regarded with particular suspicion by the unions (indeed he left Labour to set up the Social Democratic Party in 1981). Given the continuing strength of the collectivist traditions of the labour movement, the individualistic sentiments so bluntly expounded in Owen’s documents found little popular resonance. In the USA, where government concerns with escalating health care costs were even greater than in Britain and trade unionism much weaker, the doctrine of individual responsiblity for health won greater approval (US Department of Health, Education and Welfare 74 THE POLITICS OF HEALTH PROMOTION 1979, 1980). Federal health promotion connected with a growing interest in self-help and consumerism, and with the vogue for jogging, marathon running and other forms of physical fitness, which reached Britain a few years later. Government health promotion initiatives in the 1970s provoked a vigorous radical response, particularly in the USA. In a classic paper which anticipated subsequent trends with uncanny accuracy, the American sociologist Irving Zola commented that medicine was ‘becoming a major institution of social control’ (Zola 1972). He discerned a tendency towards the ‘medicalising’ of much of daily living which was proceeding in ‘an insidious and often undramatic’ way. Furthermore he noted that ‘the list of daily activities to which health can be related is ever growing and with the current operating perspective of medicine it seems infinitely expandable’. In the late 1970s, another American sociologist, Robert Crawford, characterised health promotion as ‘victim-blaming’, an ‘ideology which blames the individual for her or his illness and proposes that, instead of relying on costly and inefficient medical services, the individual should take more responsibility for her or his health. At- risk behaviour is seen as the problem and changing life-style, through education and/or economic sanctions, as the solution’ (Crawford 1977). On the one hand, they served to ‘reorder expectations and to justify the retrenchment from rights and entitlements for access to medical services’.
The key change of the 1990s is that long-tolerated variations in styles and standards of medical practice have suddenly been judged to be ‘unacceptable’ discount citalopram 40mg on line. This judgement was made buy generic citalopram 20 mg on-line, at least in the first instance order 20 mg citalopram with mastercard, not by the public or by the media, but by doctors themselves. One of the ironies of this shift is that it has taken place after a period of dramatic improvements in standards. One of the key demands of reformers, from both inside and outside the medical profession, is for an increase in the proportion of non-medical, lay members on the GMC. In the aftermath of the Shipman case, more radical critics of the GMC proposed that it should have a lay majority, thus effectively bringing professional self-regulation to an end. Lay members were first introduced onto the GMC in 1950 and their numbers have increased substantially in recent years. Though reformers seem to assume that lay members provide some sort of representation of the public, the mode of selection—by appointment by the Privy Council—means that they are more an instrument of state control than a mechanism of democratic accountability. Leading figures in the RCGP assert that the ‘input of lay people is critical to ensure coverage of areas to do with communication and attitudes to patients’ (Southgate, Pringle 166 CONCLUSION 1999). Yet they do not explain why lay people should be better judges of these matters than doctors who have both professional and personal experience of doctor-patient interactions. Nor do they indicate the nature and scale of the lay input, or how such people would be selected, trained or paid. Following the pattern of such appointments to diverse quangos, they could be expected to be selected according to their loyalty to New Labour and its leadership. The willingness of doctors to concede the right to judge their fitness to practise to those who include such cronies and toadies reflects an alarming loss of professional self-respect. The independent general practitioner, competent on qualifica- tion, symbolised the confidence of the medical profession in the nineteenth century. By contrast, the ‘never quite competent’ GP, one who requires continuous formal instruction and regulation, mentoring and monitoring, support and counselling, symbolises the abject state of the profession at the start of the new millennium. But, while some GPs are drawn into the process of assessing their colleagues’ fitness and many more are continuously collecting evidence to justify their fitness to practise, who will see the patients?