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In contrast order lasix toronto, if an athlete is training for power point exercise to condition the transversus buy 40mg lasix, while we with a heavy set of squats buy lasix without a prescription, but feels that he/she recov- may use a prone or side-lying exercise to condition ered from the previous set within 90 seconds order lasix with amex, he/she the multifidus. This means that in the javelin throw in general, the trunk must the Type 2a fast oxidative fibers will be recruited, with rotate to generate force, we are not looking for the result that it’s not the explosive Type 2b fast gly- the kind of bracing described by McGill (2002) colytic fibers that are being conditioned. The training and Siff (2003); instead we are looking for an in this instance would actually make the athlete abdominal hollowing to allow for both stability and mobility (see ‘Inner unit’ above). We 4A Trendelenburg sign indicates weakness, inhibition or should see a uniform hollowing throughout the paralysis of the gluteus medius of the weight-bearing leg. In gait, a Trendelenburg sign is classically observed as a tail-wag – often volitionally accentuated in catwalk before release of the javelin. A compensated Trendelenburg may also occur where, hollowing, and/or hollowing of just part of the rather than letting the pelvis drop, the patient leans their body abdominal wall, is a failed assessment. With (in the frontal plane) over the leg of the weak gluteus medius experience this can be seen at full speed – during weight-bearing. The stick test allows the examiner to apply graduated load to the patient’s spine and observe for dysfunction in a more controlled manner than, for example, loading the spine with a barbell. It also allows for assessment within the neutral zone, thereby minimizing risk of injury. The stick test Use a wooden dowel rod (or equivalent) and ask the patient to take hold of it firmly with both hands and hold it up in front of them – shoulders flexed to 90°. The patient should be stood with their back to a mirror, with the examiner looking over their shoulder to observe the response of their back in the mirror. Explain to the patient that you are about to move the stick in various directions and that this process will start with light pressure, but the intensity of the movements will gradually increase. Start by lifting up the stick in the sagittal plane (flexion- extension of the shoulder joint) and observe for striations in the patient’s back. If striations are noted, the side, the spinal level, and the severity of the striation should be noted (usually with a subjective descriptor such as ‘mild’, ‘moderate’ or ‘severe’). Next, try to push the patient into lateral flexion using the stick – this is testing for frontal plane stability. Finally, try to rotate the patient via the stick – thereby assessing transverse plane stability. Combinations of the above motions and sudden changes in force provide a more functional assessment of the patient’s ability to maintain functional stability in the lumbopelvic region. This is a common outcome for those In the example given above, the same exercise has who use weight training without truly understanding been used to induce a different postural effect, while subtleties of the physiological adaptation they are tar- achieving similar performance goals. A more common clinical example may the extension with 2–2-6 tempo means that the patient is chronic back pain patient who needs to retrain their working their gluteus maximus for 10 seconds for multifidus. Since a part of the means by which the each repetition, but for 6 seconds in its inner range lumbar multifidus stabilizes the lumbar spine and and for 4 seconds in its outer range. This exercise is sacrum is through the hydraulic amplifier mechanism useful to correct a patient with a lower crossed pos- (Chek 2002, Lee 2004), this system requires that the tural pattern. The supine hip extension with the 4-4-2 multifidus has good trophic levels – if it is atrophied, tempo works the gluteus maximus for 10 seconds per the mechanism is ineffective. In this case, the multifi- repetition, yet in this instance, the muscle is being dus first needs to be consciously activated through worked for 8 seconds in its outer range and only 2 isolation training, and then integrated into functional seconds in its inner range. At this stage, loads that are designed to hyper- version of the supine hip extension perfect for someone trophy the muscle (in the 8–12 rep maximum range) with a layered or sway muscle imbalance, as it trains must be prescribed for efficient restoration of the gluteus maximus to be strong in a lengthened function. Note: Contraindications to such loading would include pain, any sign of inner unit dysfunction (such as abdominal bloating or striations at the spine), lack Sequencing the client’s rehabilitation of proper conditioning and instructing on technique. Tempo allows the clinician and the patient to perform a series of exercises to fatigue the to know how much time under tension the muscle(s) abdominal wall, multifidus and gluteus medius, is receiving. It can also be used to stress different parts then is asked to squat carrying a heavy load, of the exercise. The may only be worked in the outer range (rather than supine hip extension exercise with the back on a Swiss in the critical inner range where strength needs to be ball is a descent of the squat pattern – so may also be developed). Additionally, a facilitated psoas will used to help pain patients who are unable to complete reciprocally inhibit its antagonist (Korr 1978) – the a full weight-bearing squat with axial loading. The answer is that it is all down to the relationships and optimize axis of rotation of tempo of the movement, and therefore whether the joint) targeted muscle group is being worked in its inner or 2. Exercise order should follow from most its outer range – and for how long – to create neurologically challenging to least adaptation. Swiss ball or balance board) to non-labile surfaces (the floor) • From uncontrolled environment (competitive sports)5 to controlled Figure 9. Corrective exercise program: For further description of these exercises, see Chek • Body-weight squat (taped) (1999b, 2003a). Corrective stretching program: is no antalgic posture and this low-level disc derange- • McKenzie extension push-up ment usually responds well to the McKenzie exten- → Tape the lumbar spine into neutral lordosis sion principle with corrective exercise. For example, many • Front squat exercise physiology texts caution against children lifting any kind of weight until their bones have begun to fuse (usually • Supine hip extension (back on ball) 16 yoa+). However, this defies common sense when one • Horse stance vertical considers that even during simple sprinting the child is • Lower abdominal 1 translating up to seven times their bodyweight through one leg! Compare this with a controlled supervised of (usually) L5 on S1 – but may occur at any level of environment in the gym where even lifting their own the spine. Baechle & Earle (2000) agree that there is no lower age limit when 6Assuming the diagnosis is a McKenzie derangement – one resistance training may commence. Stability of the slippage may depend might be an engram (see above for definition). For on a number of factors, including, but not limited to, example, if an elite tennis player were to be asked to pain, local muscle function and dynamic imaging. If a casual player were asked to perform the same task, their success would be sig- What is a biomechanical attractor? An attractor, used a tennis racket was asked to perform the given as described by O’Connor & McDermott (1997), is a task, the result would be almost zero serves hitting stable, reproducible state. This is because the serve pattern orbiting the sun are in an attractor state with the sun. Complex systems seem to want to revert erately impaired by negating them of their primary to some kind of stable state. In chaos theory, order feedback tool, they are able to perform the technique tends to arise from the chaos, and it is this order that with good reliability. In the preface to their book Signs of Life – How Com- Looking more to how these attractor states may have plexity Pervades Biology, Sole & Goodwin (2000) state relevance to the naturopath, it must be considered that: how, and which, attractor states arose within the New sciences combine biology with physics in a chaos of human behavior. Such attractor states will manner that allows us to see the creative fabric of provide clues as to how the human organism has natural processes as a single dynamic unfolding. To complex dynamics from which emerge characteristic do this requires some idea of the environment in patterns of order. This emergence of order from chaos eloquently Of course, knowing Homo sapiens exact develop- describes exactly what comprises a biomechanical mental environment poses some level of challenge. Goldfield’s (1995) definitions of the features The aquatic ape hypothesis (Attenborough 2002, of an attractor (Box 9. An attractor is a region of state space (the set of all states that may be reached by a system, together habitat. This suggestion offers an explanation for the with the paths for doing so) where trajectories extraordinary leap from tetrapedalism to fully come to rest. An attractor can be a point, cycle or area of state our ancestors spent much of their time wading. Wading, of course, both supports some of the body weight, as well as providing resistance to the axial 3. A physical system can have one or more attractors, and it is the number and layout of these attractors rotation of the body during gait – as described above that influence the system. The configuration of attractors has a critical influence on the behavior of the system. A change in the layout The single biggest physical stressor on the human of attractors leads to new competition between body is gravity. Gravity is relentless, stressing our attractors and results in a shift to different modes. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 363 What can be known, therefore, is that no matter • Instinctive sleep postures = Protein where in the world our ancestors evolved, gravity • Archetypal rest postures = Fats was exerting itself in exactly the same way with • Primal patterns = Carbohydrate exactly the same magnitude. This is why relatively one exercise pattern, will push the biomechanical narrow reference ranges in goniometric assessment of environment outside its functional physiological human biomechanics can be handed some level of range.

It also occurs in subarachnoid haemorrhage buy lasix 40mg otc, intracranial haemorrhage buy lasix 100mg without a prescription, anticholinergic drug overdose and heat exposure purchase lasix without a prescription. Altered consciousness 191 Handbook of Critical Care Medicine Stroke Acute stroke is a medical emergency buy lasix with paypal. Early revascularisation therapy can even reverse primary damage, and careful management can minimise secondary damage. Classification x Transient brain ischaemia (transient ischaemic attacks): arbitrarily defined as a focal neurological deficit of vascular origin lasting less than 24 hours. Risks factors for thrombotic stroke are similar to those of acute myocardial ischaemia. Embolic stroke is caused by emboli from cardiac sources (chronic valvular heart disease, old myocardial infarction, atrial fibrillation, endocarditis) or from the main extracranial vessels (carotid or vertebral atherosclerotic plaques. Causes are hypertension, bleeding tendency, amyloid angiopathy, and ruptured intracranial aneurysms. The area surrounding the stroke is known as the ischaemic penumbra, and is very susceptible to secondary damage. Careful management of perfusion and oxygenation, temperature, glycaemic control and electrolytes will prevent further damage to the ischaemic penumbra. Stroke 192 Handbook of Critical Care Medicine The main aims of management of acute stroke are: x Determine the type and cause of acute stroke. The patient maybe unable to give a clear history due to reduced level of consciousness or dysarthria / dysphasia. The presence of headache, with nausea and vomiting suggests haemorrhage, though many patients with haemorrhage may not complain of headache. Severe occipital headache of very sudden onset, with vertigo and sometimes loss of consciousness is characteristic of subarachnoid haemorrhage. Transient loss of consciousness is more common in haemorrhage but can occur in any stroke. In general, the relationship of the level of consciousness to the neurologic deficit will give an idea of the type of stroke. Most infarcts occur in the internal capsule, and such infarcts will cause significant neurological weakness without affecting the level of consciousness. A reduced level of consciousness with unilateral weakness occurs either with a massive cortical infarct, haemorrhage, or a brain stem infarct or haemorrhage. The presence of widespread malignancy may preclude the benefit of aggressive therapy. History of bleeding diathesis or warfarin therapy may indicate the possibility of a bleed. Stroke may have occurred as a result of a cardiac event (shock or arrhythmia) resulting in a period of hypotension. If the patient is unconscious, muscle tone and reflexes may be helpful in localisation. If the patient’s level of consciousness is reduced, take all precautions to prevent aspiration. If the blood pressure is too high, it may ‘flood’ the ischaemic penumbra resulting in oedema and cellular hypoxia. If too low, the vessels may dilate, leading to ‘stealing’ from the penumbra, worsening ischaemia. In ischaemic stroke, the blood pressure should be maintained between 160- 220/95-120mmHg. There is no need to start antihypertensives if the blood pressure is below 220/120mmHg. If the patient has been on Stroke 195 Handbook of Critical Care Medicine antihypertensives previously, they should be continued unless the blood pressure is low. In intracranial haemorrhage, the systolic blood pressure should be reduced to between 140-160mmHg. Arrhythmias may be present and need treatment only if they result in low blood pressure. Atrial fibrillation does not need immediate treatment unless the rate is very high and compromise blood pressure. Bradyarrhythmias may result in a drop in blood pressure, and temporary cardiac pacing maybe required. Certain conditions warrant tight control of blood pressure - aortic dissection, hypertensive encephalopathy, severe heart failure, acute myocardial infarction or unstable angina. Further management Once the initial management is complete, attention should be given to the following: Assessment of swallowing: Usually performed by giving the patient small amounts of water to drink. If the patient coughs, a nasogastric tube should be inserted and the patient fed through it for the first 2 weeks after the stroke. The presence of visual field defects and aphasia make rehabilitation more difficult. Other complications which may occur include urinary tract infections, decubitus ulcers and deep vein thrombosis. Urinary tract infections should be treated with appropriate antibiotics according to culture. Decubitus ulcers occur in relatively immobile patients, with severe neurologic deficit. Proper nursing with frequent turning of the patient and the use of an air mattress will prevent them. Seizures: While there is no indication for prophylaxis to prevent seizures, should seizures occur after an acute stroke, treatment is necessary. Stroke 199 Handbook of Critical Care Medicine Haemorrhagic transformation of an infarct may occur, especially after thrombolysis. Increased intracranial pressure occurs in haemorrhages, and in large infarcts where swelling of the infarct occurs. If decreased systemic vascular resistance is present, vasopressors such as dopamine and noradrenaline maybe necessary. Secondary prevention Aspirin: doses of 150 to 1500mg daily have, in various trials, shown to be effective in secondary prevention. In embolic stroke, where a source of cardiac or arterial embolisation has been identified, and in atrial fibrillation, anti-coagulation is necessary. Carotid stenosis greater than 70% in the artery of the affected territory is an indication for carotid endarterectomy. Risk factors: thrombotic tendency, vasculitis, severe hyperglycaemic states, dehydration, malignancy, head or neck trauma. Prevention of cerebral oedema: as detailed above, steps should be taken to optimise cerebral perfusion and reduce increased intracranial pressure. Take care not to drop the blood pressure too much, especially in patients who have reduced level of consciousness, as cerebral perfusion pressure may drop. Treatment should be started within 4 days of the event, at a dose of 60mg daily orally, and continued for 21 days. Hence, surgery for the aneurysm is often essential, unless the patient’s condition is too unstable or the patient has already suffered severe cerebral injury. Involvement of the respiratory muscles leading to ventilator failure may require assisted ventilation, or may delay weaning from ventilation. The motor unit is composed of the alpha-motor neuron (located in the anterior horn of the spinal cord or brain stem nuclei), the axon, the neuromuscular junction, and the muscle fibres innervated by a single neuron. Localisation of the defect Anterior horn cell Peripheral nerve Neuromuscular Muscle junction Muscle tone Predominantly Distribution varies. In demyelinating conditions, the amplititude is normal, and conduction velocity is reduced. Decision to ventilate should be made on the clinical condition of the patient, and the vital capacity and negative inspiratory force, and should not be delayed because of normal blood gases. Other tests which are useful in individual conditions are discussed in the relevant sections. Conditions affecting different parts of the motor unit: Motor neuron: 3 conditions cause disease of the motor neuron – poliomyelitis, tetanus and motor neuron disease (amyotrophic lateral sclerosis). Degeneration occurs in the upper motor neurons in the corticospinal tracts, and the lower motor neurons in the brain stem nuclei and spinal cord, thus characteristically resulting in a combination of upper and lower motor neuron signs in the same myotome – for example flaccid weakness, wasting, with brisk reflexes and up going plantars. The onset is usually in the th 6 decade and the condition is fatal within 2 years in most cases.

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None of the three other fracture repair order lasix with american express, myofascial trigger points cheap lasix 100mg on line, neuropathic frequency combinations tested had any effects pain and spinal cord-mediated pain in fibromyalgia on reducing inflammation purchase cheap lasix. None of these indica- inflammation buy lasix 40 mg without a prescription, 40 Hz/116 Hz produced a 30% tions can be claimed by the manufacturers or distribu- reduction of swelling which was equivalent to tors of the devices. Basic and clinical Indications, contraindications and safety research in the use of ultrasound began earlier in Microcurrent is in an awkward position in the area of Europe and especially Germany (Griffin & Karselis indications, contraindications and safety. Chapter 12 • Electrotherapy Modalities 553 The energy of ultrasound is focused to an area under the ultrasound head. It is therefore well adapted to focused treatment and less well suited to heating large areas. Therapeutic ultrasound is generally recognized for its use in, or treatment of, the following (Cameron 2003, Griffin & Karselis 1988, Hayes 2000, Shankar & Randall 2002a): • Relief from pain • Relief from muscle spasm/trigger points • Acute, subacute and chronic inflammation of tendons, bursae, etc. Photograph courtesy of Amrex-Zetron • Carpal tunnel syndrome • Healing of wounds, tendons and bone • Organized hematoma • Abnormal tissue mineralization • Transdermal drug delivery. Ultrasound produces its action through the coupling of mechanical energy into tissues. As an alternating current is applied to the piezoelectric crystal in the ultrasound head, the crystal vibrates, producing compression and rarefaction waves. The vibration energy is conducted into the tissues through an elastic coupling medium such as water or a coupling gel. Movement of the molecules of the coupling medium causes movement of the molecules of the tissues. As those molecules move, heat is generated through friction; hence the historical description of ultrasound as a diathermy modality (Griffin & Karselis 1988). Methodology Therapeutic ultrasound may be applied with either a continuous or a pulsed output. See common to most ultrasound devices, but some discussion under ‘Physiological effects’ below. The devices are available with interchangeable intensity of treatment (power) may be varied between 2 heads of different frequencies) 0. Either water or a coupling gel is • implanted medical devices (insulin pumps, adequate and appropriate for this use. Thus • the pregnant uterus underwater treatments are best for areas that are small • malignancies or suspected malignancies or uneven, such as the hand, wrist, foot, etc. Large flat • thrombophlebitis areas such as the low back or shoulder are appropriate for the use of a coupling gel. Once the above decisions are made as to the appro- Special care must be taken when applying ultra- priate treatment parameters, the treatment is per- sound in the following cases: formed with a constant motion of the ultrasound head over the desired treatment area for the duration of the • in the presence of orthopedic pins or artificial treatment. It is beyond the scope and intent of this • over areas of hypo- or dysesthesia text to provide an exhaustive description of each, but • in the presence of vascular insufficiency consider the following: • over fractures 1. To apply the same high degree of safety, and patient response to treat- ‘dose’ to a larger treatment area, either the ment is generally positive and rarely, if ever, duration or the power (intensity) of the negative. Cameron (2003) and Griffin & Karselis (1988) cite For more on this subject, see ‘Physiological effects’ numerous studies demonstrating the effectiveness of below. Absorption is meta-analysis performed and published by Gam & greatest in tissues with high collagen content (Cameron Johannsen (1995) and a systematic review performed 2003, Griffin & Karselis 1988, Hayes 2000, Shankar & and published by van der Windt et al (1999) in which Randall 2002a). Therefore they concluded Intense heating may occur in these areas, leading to a that there was little evidence to support the use of pathological temperature increase. The periosteum is ultrasound in the treatment of musculoskeletal richly supplied with sensory receptors, including disorders. Therefore, in persons with a nor- It should be remembered that studies which fail to mally functioning sensory nervous system, pain will prove efficacy do not, by default, prove the modality alert them to danger long before harm is done (Griffin to be ineffective. Other common contraindications to the use of ultra- Alternatives sound (Cameron 2003, Griffin & Karselis 1988, Hayes 2000, Shankar & Randall 2002a) include treatments Depending on the physiological effect desired, there over: may be several alternatives to ultrasound. The thermal effects of ultrasound (Cameron 2003, Cross-fiber releasing and myofascial release tech- Griffin & Karselis 1988, Hayes 2000, Shankar & Randall niques may be useful in the release of scars and adhe- 2002a) include: sions, though again these may not be as effective in • increased tissue extensibility (tendon, ligament, deep tissues. This is believed to alter of ultrasound in a pulsed mode eliminates most of the cell membrane permeability and facilitate transfer of thermal effects of the modality. Microstreaming Manipulation of the depth of penetration of ultra- describes the eddying that takes place near any sound is accomplished to some extent by the choice of frequency generated by the device. With stable cavitation, bubbles vary in Stimulated Emission of Radiation) light (Belanger size but do not burst. Laser light is a focused beam of light that grow and implode, which may cause local tissue emits photon energy. It is believed that generated by the gaseous helium-neon (HeNe) unstable cavitations do not occur at the intensity laser, the gallium arsenide (GaAs) and the gallium levels used for therapeutic ultrasound. The mode of delivery Several theories have been presented to explain the may be continuous or pulsed through probes or grids phenomenon, but the exact mechanism of action is applied perpendicularly to the treatment surface, unknown. It is thought that ultrasound increases both either in direct skin contact or above the skin in a skin permeability and cell membrane permeability, sweeping fashion. Unlike the from 15 to 30 seconds up to 2 minutes, or longer in use of iontophoresis for drug delivery, phonophoresis certain instances. Anti- inflammatory agents and analgesics have been com- Mechanism of action and physiological monly used in phonophoresis. Laser light works by initiating athermic photo- fits well within naturopathic practice. It is certainly chemical reactions within specific wavelengths and agreed that, for purposes of clinical science, addi- frequencies on dependent tissue chromophores within tional, well-developed research should be done to cell membranes and organelles (mitochondria) (Smith determine the efficacy of ultrasound in many of its 1991). However, given its low cost, low risk of The physiological effects of laser therapy are con- harm and clinical evidence of efficacy, it would seem sidered to be from a photobiomodulation effect. This likely that ultrasound will remain a useful tool for the effect may be either stimulatory or inhibitory. Tinnitus and immune modulation have also shown benefit from laser therapy (Basford 1993, Belanger 2002c, Kahn 2000, Shankar & Randall 2002b). Naturopathic indications and applications: validation of efficacy = 2 Naturopathic clinical application of laser therapy is to stimulate cells and tissues to bring them back to their most natural state by photonic absorption converting into chemical energy which initiates a cascade of events at a cellular level. This is an evolution of the naturopathic therapeutic use of heliotherapy Figure 12. Photograph courtesy of Mettler Electronics (sunbaths) to stimulate a healing response. The clinical vignettes are purposely placed in random order to simulate the way that real patients present to the practitioner. Finally, we intentionally did not use a multiple choice question format in the case sce- narios, because clues (or distractions) are not available in the real world. Approach to the Patient The transition from the textbook or journal article to the clinical situation is one of the most challenging tasks in medicine. Retention of information is difficult; organization of the facts and recall of a myriad of data in precise application to the patient is crucial. This includes taking the history (asking questions), performing the physical examina- tion, and obtaining selective laboratory and/or imaging tests. Sensitivity and respect should always be exercised during the interview of patients. Clinical Pearl ➤ The history is the single most important tool in obtaining a diagnosis. All physical findings and laboratory and imaging studies are first obtained and then interpreted in the light of the pertinent history. Basic information: Age, gender, and ethnicity must be recorded because some conditions are more common at certain ages; for instance, pain on defecation and rectal bleeding in a 20-year-old may indicate inflammatory bowel disease, whereas the same symptoms in a 60-year-old would more likely suggest colon cancer. The patient’s own words should be used if possible, such as, “I feel like a ton of bricks are on my chest. It is often useful to clarify exactly what the patient’s concern is, for example, they may fear their headaches represent an underlying brain tumor. History of present illness: This is the most crucial part of the entire data- base. The questions one asks are guided by the differential diagnosis one begins to consider the moment the patient identifies the chief complaint, as well as the clinician’s knowledge of typical disease patterns and their natural history.

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Like a lightning conductor at grave risk to themselves purchase 100mg lasix with amex, doctors place themselves between the sick and society buy generic lasix 100 mg online, transforming the evil of illness into the goodness of health buy discount lasix 40mg. Delatte has been known to store bacteria and other ingredients for his powder in a domestic freezer order discount lasix line, mixing it up in an ordinary kitchen, using normal kitchen scales, and taking no special 78 precautions, such as gloves or overalls, to maintain hygiene or sterility. Several kilograms of the bacteria Delatte had imported were then left in her fridge. Soon afterwards, Smith suffered severe headaches and sinus pains, probably caused by the dried faecal bacteria left floating in the kitchen 79 atmosphere. By juxtaposing the kitchen, a designated sterile place, with faecal bacteria, Campbell creates the impression of something profoundly polluting. Probion was manufactured by a reputable pharmaceutical company in Sweden under strict controls. Production was carried out for the Company by a Pharmaceuticals manufacturer at its laboratories under strictly controlled conditions. It transpires in the article that not only is Delatte a foreigner, he was also, for a time, an illegal immigrant in Finland. The article carried a photograph of Delatte in a prison cell where he was being held as an illegal immigrant. During his period with Bryant, he was thrown out of his home by his wife, was grieving over his father who died shortly after he arrived, and spoke of needing to appear in court over an unknown matter. The kernel of the article, however, has nothing to do with Delatte as a health worker, or research scientist, nor with Monica Bryant, nor any of their probiotic preparations. Sandra Goodman was made out to be a mercenary and shady business associate of Monica Bryant. Last year, Sandra Goodman published a book, Germanium -the health and life enhancer. In fact, though Goodman may not have benefited directly from sales, Bryant admitted three months ago... None of these obvious omissions occur when Campbell writes about Vincent Marks, the Surrey company director, founding member of the Wellcome-funded Campaign Against Health Fraud, and a consultant to the International Sugar Bureau. She asked the research workers whether the compound they had studied had been germanium dioxide or germanium sesquioxide. The reply which she received from Dr Kaoru Onoyama, Assistant Professor, 2nd Department of Internal Medicine, at Kyushu University, was clear: the label on the bottle indicates that organic germanium (Ge) is contained. But after that paper, we found that all the materials, those patients used [the patients who had kidney damage], contained GeO2 (Germanium Oxide), irrespective of the description of organic Ge on the label. Thereafter, we have studied the difference between GeO2 (Germanium Oxide) and organic Ge... The letter from Japan and this new information, helped her to put her own predicament into perspective. Regardless of this, she was not approached by anyone to give her opinion about germanium, and when Radio Four broadcast an item on germanium, they called on Vincent Marks. With improbable speed, the Campaign and its supporters in the Department of Health got an investigation by the Medicines Control Agency into both Yves Delatte and Monica Bryant. The charges related to the possession and sale of unlicensed medicines, and the supply of those medicines to patients without a licence. Dreer, who had been advised by his solicitor to plead guilty, appeared in court on behalf of the Company which he and Delatte had set up. In fact, there has never been any dispute about the fact that lactic acid bacteria are food supplements and not medicines. Yves Delatte was also charged personally and his plea was entered by his solicitor in his absence; much later in January 1992, he was fined £350 plus costs. Bryant was prosecuted by the Department of Health for articles she had disseminated on selenium, chromium and germanium. She was accused under the Medicines (Labelling and Advertising to the Public) Regulations of making medical claims for these trace elements. The acquittal hearing was held in July 1991, at Brighton Magistrates Court, where Bryant was awarded nearly £11,000 in costs from central funds. It took over three years for Monica Bryant to become confident enough to trust a limited number of people and to venture out into the world again. Yves Delatte is still fighting to gain access to his children, and prove in a Finnish court that he is not the monster which Campbell claimed. Sandra Goodman was forced into a temporary retirement from scientific research, although her energy is undiminished. Looking back on the whole affair which has damaged his life and career, Yves Delatte remembered something said by Dr Connolly when they were chatting about the Concorde trials. A Contemporary Salem: Elizabeth Marsh nl The issue was very simple, I had treated a cancer patient When Elizabeth Marsh decided to become a therapist and a healer, her decision had nothing to do with any well-ordered course of medical training, or any previous history in the field of health. Until 1981, when she was suddenly deserted by her business partner who left her with an £80,000 debt, Elizabeth Marsh had made reproduction antique dolls. In the middle of this turmoil and having to move out of her house, she suffered the loss of her brother from cancer. Following this period of crisis she set about, in any possible way, outside of orthodox medicine, learning about cancer. Later in 1981, she travelled to Romania, where she worked and studied at the National Institute of Gerontology, in Bucharest, with Professor Ana Asian. Following the year in Romania, from 1986 to 1987, Marsh joined the Bedfont Theological Seminary, a theological college which specialises in healing. On the conclusion of her training in 1988, she was ordained as a Minister, and also received a PhD, which entitled her to use the title doctor. Over the next ten years, the diverse and unusual training which Elizabeth Marsh went through, together with the tides which she used, were to attract the attention of health fraud campaigners. It would indeed have been surprising, if in her journey through the far reaches of alternative therapy, Elizabeth Marsh had not been associated with one or more of the organisations on the lists of the American Council Against Health Fraud. Other things, as well, have brought American Biologies into direct confrontation with the orthodox pharmaceutical medicine lobby. Bradford, the Institute carries out research and publishes on subjects as diverse as cancer and nutritional therapies and chelation therapy. When Elizabeth Marsh came back from training in America, she brought with her an American Biologies microscope produced for the diagnostic analysis of live blood cells. She became one of the first people in Britain to begin diagnostic work using this equipment. In September 1988, Elizabeth Marsh set up a therapy centre in Ealing where she began practising homoeopathy, electro-acupuncture and signalysis treatment. The practice took off well, and within months she was seeing between forty and sixty clients a week. From the beginning of her practice, Elizabeth Marsh was always scrupulous about telling patients that she was not a qualified medical doctor and asked people who came to her to sign a form acknowledging that she had told them this. She also told patients that they should inform their general practitioner about the treatment they received from her. Problems began with her practice in May 1989, the very month that the Campaign Against Health Fraud held its inaugural press conference. In April 1989, a patient had visited Marsh with very general complaints; he claimed that he felt under the weather and was unable to sleep. A week after the consultation, Marsh was phoned by the patient who revealed that he was a reporter. He asked her a number of questions for a forthcoming article, all of which she answered. She gave him the names of all the people she had worked with and the organisations from which she had received her qualifications. As well as Elizabeth Marsh, east London readers of the People could have justifiably taken offence. It is the contention of those who work with this system that the crystal structure is not only personal to the patient but also can indicate problems in different areas of the body. Results of Signalysis tests come back to the practitioner from the Signalysis laboratory in Gloucestershire, in the form of charts. In the event, Elizabeth Marsh did not consider that the bogus patient Mark Howard needed a Signalysis test. Determined to continue her work, Marsh began seeing people at her home where she used her study as a consulting room. Julia Watson was a writer of romantic novels, under the pen name of Julia Fitzgerald.

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