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Houston Merritt Scholarship Fund cation This scholarship fund will be used Established in 1990 with a gift from the estate to support a medical student with fnancial of H order acivir pills 200 mg amex. Martin is a 1950 graduate of the School of Adolf Meyer Scholarship Established by a Medicine buy 200mg acivir pills fast delivery. Bessie Darling Black Fund This fund was established in 2003 by Massey; the income is to be used for scholar- the Mildvan family to honor their devotion to ships in the School of Medicine. The Manfred Mayer Scholarship Fund Estab- income from this fund is to be used to assist lished in 1985 by the colleagues and friends students in the Five Year Program with pref- of Dr. Manfred Mayer to provide scholarships erence to be given to students from the state to support needy medical students with spe- of Oregon. The scholarship was established in honor John Scott McFarland Scholarship Fund of Dr. Moore’s 35th School of Medicine An endowment fund established in 1965 Reunion, with income to be used to provide under the will of Dr. McFarland, a scholarship assistance to fnancially needy member of the Class of 1902. McGraw Scholarship Fund This Morawetz are available to students in the scholarship was established by The McGraw School of Medicine who are in need of fnan- Foundation in April 1983 with the purpose of cial support. Sandra Morse Scholarship Fund This This fund was established in 1974 by an fund was established in 1993 by M. The income is to be used to sup- cal school students had given her during her port fnancially needy students in the School 29 year tenure as Director of Financial Aid. Edwin Leonard McQuade Scholarship vide assistance to fnancially needy students Fund The income from this endowment, in the School of Medicine. Donald Scholarship This fund was established Mulder established this endowment fund to provide tuition scholarships to medical to provide scholarships for needy medical students. Myatt Parker Endowed Scholarship Fund Estab- Memorial Scholarship Established by the lished in 1996 by Ronald E. Myatt, in memory of her and provide scholarship support to students in the her spouse, Leslie, School of Medicine Class School of Medicine. Park Scholarship Fund An Jesse Myers Scholarship Fund Established endowment fund, established by friends, for- in 1971 in memory of Jesse Myers, who was mer students, and professional colleagues killed in an automobile accident while he was of Dr. Park at the time of his eightieth birth- a First Year student in the School of Medi- day, December 30, 1957, with income allo- cine. The fund is to be used to assist minority cated to student scholarships in the School students at the School of Medicine. This fund provides scholarship whose paintings hang in the Johns Hopkins assistance to deserving medical students in University and Hospital. Payne Scholarship Fund This Nu Sigma Nu Medical Student Scholar- endowment fund was established by Mr. William Hillis, an alumnus of Samuel Payne and to provide scholarships the School of Medicine and a former mem- for deserving students from the state of ber of our faculty. Penney Memorial Scholarship Medicine, and it gives recognition to the past Fund An endowment fund was established in contributions of the Nu Sigma Fraternity to 1986 by Della N. Giacomo and Jan Pirzio-Biroli Scholar- Paul O’Sullivan, a graduate of the School of ship Fund This fund was endowed in 2001 Medicine in 1943, to provide scholarships to by the estate of Giacomo Pirzio-Biroli, Class fnancially needy medical students. Reinhard Medical Scholar- to experience similarly enlightened medical ship These are endowed scholarships made education in the tradition of Johns Hopkins. Reinhard, a graduate of the Fund Family, friends, and former classmates School of Medicine. The fund provides fnancial assis- this fund provides scholarships for medical tance to deserving students in the School of students with preference given to Jewish Medicine. Richardson Fund Established Established in 1980 with a gift from the estate as a bequest from the estate of Dr. The income from this fund is to scholarship aid to students in the School of be used for scholarships for worthy students Medicine. Alvin Riebling Scholarship Fund A gift general practitioners in the feld of family from Dr. Rosenfeld Scholarship Fund ment, established in 1993, is used to provide Established in 1990 by the Estate of Madalyn scholarships for students in the School of Schwentker Rosenfeld, this fund in memory Medicine. Rosenfeld’s father, Jesse Rosen- Radiology Fund for Medical Students feld, his mother, Rose R. Morgan Depart- sister, Carolyn Rosenfeld, is to be used to ment of Radiology and Radiological Science provide students residing in the state of Mary- has established a scholarship fund for medi- land with scholarship support. Raider Scholarship Fund Estab- this fund in 1959 in memory of an eminent lished by Mr. Raider to pay the tuition and/or graduate of the School of Medicine, Class other expenses of worthy students enrolled in of 1900. Memorial Scholarship Medical School in 1993, and died suddenly Fund An endowed fund established in 1996 after a brief illness in 1995. Sapre, family, friends, and this fund is to provide scholarship support to colleagues of Dr. The income students who exemplify the highest ideals in is to provide scholarship assistance to needy the medical profession.

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In the asymptomatic patient generic acivir pills 200mg without a prescription, a the conditions along lobar margins purchase acivir pills 200mg otc, with wider trapped lung presents as a diagnostic dilemma separation of the pleural surfaces, a steeper pressure rather than a condition requiring treatment. If trapped lung is suspected, a thera- A trapped lung can develop from an infection, peutic thoracentesis with pleural manometry should a noninfectious inflammatory process, hemor- be performed. Complete expansion drainage, or both—can lead to the development of of the lung after thoracentesis is inconsistent with lung entrapment and eventually a trapped lung. These Trapped lung should be included in the dif- patients often have a history of a persistent pleu- ferential diagnosis of a stable, persistent pleural ral effusion for months to years. Patients with dyspnea on exertion ema, appropriate antimicrobial therapy and timely and restrictive physiology should be considered drainage of the pleural space will typically prevent for decortication if the underlying lung is normal. Effusions after cardiac surgery and Clinical Pearls tuberculous pleuritis tend to resolve spontaneously or with the administration of drug therapy before • Trapped lung, a result of visceral pleural restric- the development of visceral pleural fibrosis. When tion, is a cause of a persistent, benign, constant- an active pleural process has been excluded and volume effusion that is not associated with active there is no further explanation other than a pleural infection or inflammation or malignancy. In a symptomatic substernal chest pain is a constant finding that patient, the likelihood of improvement after decor- is a consequence of a significant decrease in tication and the feasibility of surgery should be pleural pressure. In contemplating surgery, the gen- • Asymptomatic patients with a trapped lung eral health of the patient and the mechanics of effusion do not require treatment. Ideally, • Decortication should be considered in patients the elastic membrane that covers the visceral with exertional dyspnea and restrictive physi- pleura can be easily separated from the pleura ology and normal underlying lung. Symptom- atic persistent post-coronary artery bypass graft Yellow or unsightly nails are the initial finding pleural effusions requiring operative treatment: in only one-third of patients. Women frequently cover their unsightly nails with opaque nail polish that can obscure the The differential diagnosis of a persistent, finding from the unsuspecting observer. Effusions that last several months, 60% of patients during the course of the disease, but not years, include benign asbestos pleural whereas a third present with a respiratory mani- effusion, uremic pleurisy, rheumatoid pleurisy, festation. The nucleated cell count is that result in impaired drainage and obstruction, usually 2,000/ L with a predominance ( 80%) leading to subungual edema, periorbital edema, of lymphocytes. The growth and • A history of bronchiectasis, chronic bronchitis maintenance of these endometrial implants are (in a nonsmoker), chronic sinusitis, or recurrent dependent on the ovarian steroids; therefore, endo- pneumonias in association with a chronic pleu- metriosis occurs only in women of reproductive ral effusion or peripheral edema suggests the age or in those women who are receiving estrogen diagnosis. Endometriosis typically • Slow nail growth is the most consistent nail involves the pelvic structures, particularly the finding and is more common than yellow dis- ovaries, cul-de-sac, broad ligament, and uterosac- coloration of nails; women often cover their ral ligaments. There were 110 cases of thoracic • The diagnosis can be established when at least endometriosis reported in the English-language literature between 1966 and 1994. Catamenial pneumothorax occurred in 80 552 Pleural Pearls (Sahn) (73%) of 110 cases, catamenial hemothorax in 15 to earlier diagnosis and timely, specific therapy (14%), catamenial hemoptysis in 8 (7%), and lung with decreased morbidity. Movement of endometrial tissue from the peritoneal to pleural cavity can occur either The goals of treatment are twofold: eradication through congenital diaphragmatic defects, which or suppression of thoracic endometrial tissue and occur more commonly in the right diaphragm, or prevention of reseeding from the pelvis. Therefore, oral contraceptives, progestins, Clinical Presentation danazol, or gonadotropin-releasing hormone ana- logs have all been used to suppress ovulation. At presentation, the mean age of women with Unfortunately, ovulation suppression appears to thoracic endometriosis is 35 years (range, 19 to 54 be effective in less than half of the patients. Pleural implants, however, were abrasion, partial pleurectomy, and chemical found in 15% of patients who underwent thora- pleurodesis through a chest tube. However, even costomy or thoracotomy, whereas diaphragmatic with a successful pleurodesis, patients may still defects and/or parenchymal cysts or blebs were develop catamenial chest pain as long as endome- observed in 25% of patients. Recurrent Patients with thoracic endometriosis typically symptoms are presumably the result of cyclical have symptoms within 24 to 48 h of the onset of proliferation of the pleuropulmonary endometrial menstruation; however, catamenial symptoms may implants in response to ovarian estrogens. Chest pain is symptoms can be relieved by hysterectomy with the most common symptom, occurring in 90% of bilateral salpingo-oophorectomy but may recur if patients; dyspnea occurs in about 30%. Catamenial estrogen replacement therapy is initiated and dor- pneumothorax is almost exclusively (95%) a right- mant thoracic endometrial tissue is reactivated. Diagnosis Clinical Pearls The diagnosis should be considered in a woman of reproductive age who presents with a • Thoracic endometriosis is a clinical diagnosis pneumothorax (nonsmoker), hemothorax, hemop- in women who develop right-sided pneumo- tysis, or chest pain associated with menses. The onset of a bronchopleural fistula, which may be dramatic, with acute fever, dyspnea, and References production of copious, mucopurulent sputum, not only heralds the disease but increases the risk of 1. Thoracic endometriosis syn- stitutional symptoms, such as fatigue and weight drome: new observations from an analysis of 110 loss, and also manifest low-grade fever and night cases. Visualization of mon site for empyema necessitatis is in the subcu- diaphragmatic fenestration associated with catame- taneous tissues of the chest wall; therefore, patients nial pneumothorax. Before the development of antituberculous medica- Chronic Tuberculous Empyema tions, Mycobacterium tuberculosis was the most common cause of empyema necessitatis. Defnition and Causes Radiographic Findings Chronic tuberculous empyema, an entity dis- tinct from and much less common than tuberculous The typical chest radiographic finding of pleural effusion, represents chronic, active infec- chronic tuberculous empyema is a moderate-to- tion of the pleural space. Chronic tuberculous large, loculated pleural effusion with pleural calci- empyema can occur in several settings: (1) progres- fication and enlargement of the overlying ribs due sion of the primary tuberculous effusion (usually to the chronic infectious process. In addition to tuberculous 554 Pleural Pearls (Sahn) empyema, the differential diagnosis of empyema serial, space-emptying thoracenteses and 24 necessitatis includes bacterial empyema, lung months of isoniazid, rifampin, and ethambutol. Thoracentesis was repeated bimonthly for the first 2 months, monthly for 3 months, and less Pleural Fluid Analysis frequently as the fluid reaccumulated more slowly. Twenty-four months of therapy was cho- The definitive diagnosis of tuberculous empy- sen based on the rate of improvement of the ema is established at thoracentesis by finding 6 pleural fluid by laboratory parameters.

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Healing of tissues is years ago purchase 200 mg acivir pills, when I had an accident at finished work Where is your pain? In my back and down both legs This pattern of pain is plausible and warrants further questioning On a scale of 0–10 discount acivir pills 200 mg visa, how would you 10 out of 10 A maximal pain rating is suspicious for rate your pain? With deconditioning and secondary joint pathologies, his pain response to all activities seems likely What makes your pain better? Medication and lying down make it He has a passive lifestyle, is displaying better avoidance behavior and is dependent on medication How many hours do you lie down? His waking up at night may be due to depression What can you now not do because of I used to walk 20 minutes every day. I can stand for 6 and could be based on his low minutes expectation for function What activities do you do outside of I used to go bowling and socialize This activity tolerance could be work? Now my ex-wife or mother comes The patient’s family may contribute to his over to do everything illness behavior Do you work? I hate my Apparent job dissatisfaction is a common boss problem contributing to disability How long were you working at this job? This predicts a poor outcome in rehabilitation Are you thinking of going back to your No, I am applying for disability This answer demonstrates passive job? Make use of psychiatric something could be done for my pain expertise for assistance. If never diagnosed in the patient, find out about the family What would you do a year from now if All my problems would be solved. Cleland et al (2006) stretching demonstrated significantly greater conducted a study to determine whether low improvements in disability, pain, and back pain and disability improved, together centralization of symptoms than patients who with centralization of symptoms, when slump did not (see Fig. All patients manipulation than to dummy (simulated) were treated in physical therapy twice weekly manipulation (Santilli et al 2006). At • Manipulation for neck pain: In a randomized discharge, patients who received slump controlled trial 70 patients with mechanical 486 Naturopathic Physical Medicine Figure 10. Patient was instructed to sit erect with knees in 90° thoracic manipulation, compared to placebo of flexion. The presence or absence of symptoms manipulation, in patients with neck pain was recorded. Patient was instructed to ‘slump’ shoulders and high velocity thoracic spine manipulation (Fig. The presence or absence of symptoms was patients with mechanical neck pain and recorded. While maintaining the position described in step 2, • Exercise, advice for chronic whiplash symptoms: the patient was instructed to tuck their chin to the Chronic whiplash pain, and associated chest and the clinician applied overpressure into disorders, that persist beyond 3 months cervical flexion. The presence or absence of following the trauma are not commonly symptoms was recorded. A randomized, assessor-blinded, flexion the patient was instructed to extend the controlled trial was conducted at two centers knee. Position 4 was maintained while the patient was addition, the experimental group participated instructed to actively dorsiflex the ankle. Overpressure of the cervical spine was released progressive, submaximal program designed to and the patient was instructed to return the neck to improve participants’ ability to complete a neutral position. The presence or absence of functional activities specified by the participant symptoms was recorded. As well as a home exercise program, each participant The slump test is considered positive if the patient’s symptoms carried out a form of aerobic exercise (e. Reproduced with permission from Cleland et al (2005) endurance and coordination, and trunk and hundred patients were enrolled in a limb strengthening exercises. In outcomes were pain intensity, pain the standard group, treatment consisted of bothersomeness and function, measured at 6 immobilization with a soft collar over 7 days. High levels of baseline In the physical therapy group, patients were pain intensity were associated with greater scheduled for 10 physical therapy treatment effects at 6 weeks, and high levels of appointments including active exercises within baseline disability were associated with greater 14 days after enrolment. In the short were randomly assigned to the standard term, exercise and advice are slightly more treatment group and 103 to the physical effective than advice alone for people with therapy group. After 6 weeks, mean pain persisting pain and disability following intensity was significantly (p = 0. Similarly, after 6 months, significantly (p authors note that: ‘The small, short-term effect <0. The to be effective for this treatment-resistant conclusion was that a physical therapy protocol patient group. Two upslip, downslip, posterior or anterior fixed 488 Naturopathic Physical Medicine Figure 10. Reproduced with permission from Horton & Franz (2007) A innominate) and may be treated by case study (20 m shuttle run, 20 m and 5 m manipulation or mobilization (including sprint tests) are frequently employed in muscle energy techniques) (Walker 1992). All Alternatively, Lee (2004) has proposed a players were commenced on a conservative complex classification system based on an rehabilitation program involving abdominal integrated model of function. Treatment and pelvic strengthening exercises in a techniques proposed to correct ‘biomechanical graduated format and successfully achieved dysfunctions’ include belt fixation, mobilization this outcome between 10 and 16 weeks after and manipulation procedures. Rehabilitation included completion massage are also purported to correct muscle of a running program consisting of durations imbalance together with a corrective exercise and elements specific to football.

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