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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 buy levitra soft with amex. During their program to restore joint position generic levitra soft 20mg mastercard, including the rehabilitation a consistent pattern of clinical hip joint cheapest levitra soft. If manual techniques fail to resolve milestones emerged that coincided with the the pain, then prolotherapy injection therapy players’ readiness to return to football. The clinical outcome measures with chronic groin pain from osteitis pubis included strong effort pain-free hip adduction, and/or adductor tendinopathy. Twenty-two with no tenderness over the pubic symphysis, rugby and two soccer players with chronic bone or adductor complex. The functional groin pain that prevented full sports outcome measure involved a pain-free participation and who were non-responsive completion of a running program based on both to therapy and to a graded reintroduction average distances covered by players in a into sports activity received monthly injections game. Injections were given surprising finding was that muscle activity levels until complete resolution of pain or lack of and postural changes had the largest impact on improvement for two consecutive treatments. The mean Comment: These findings highlight the need reduction in pain during sports, as measured for postural re-education tasks to be graduated by the visual analog scale, improved from 6. Of the 24 patients, 22 had no pain and • Trigger point deactivation method: Treatment of 22 of 24 were unrestricted with sports at final myofascial (trigger point) pain was evaluated data collection. Conclusion: Dextrose in a study that compared a single application prolotherapy showed marked efficacy for of ischemic compression technique with chronic groin pain in this group of elite rugby transverse friction massage (Fernández-de- and soccer athletes. Subjects were was based on the guidelines provided by divided randomly into two groups, one of Kendall et al (1993). The author states: which was treated with the ischemic compression technique (see Fig. Ischemic and sternocleidomastoid muscles of the dominant compression technique and transverse friction side of each of 18 healthy subjects. Corrected posture in standing required more It has been suggested that the origin of the pain muscle activity than habitual or forward head noted in fibromyalgia may also derive in large part posture in the majority of cervicobrachial and jaw from muscular ischemia (Henriksson 1999). The ratio- muscles, suggesting that a graduated approach to nale for this observation can be summarized as postural correction exercises might be required in follows: 490 Naturopathic Physical Medicine A B Figure 10. The external auditory meatus, the lateral acromion and the greater trochanter should lie along a plumb line. The external auditory meatus, the lateral acromion, the greater trochanter and the lateral malleolus should lie along a plumb line. Reproduced with permission from McLean (2005) • Morphological abnormalities have long indicated that ischemia is a feature of these muscles (Bennett 1989). Note, however, that normal muscular vascularity is seen in the non-contracting deltoideus muscle in the upper right-hand corner. Reproduced with permission from Elvin et al (2006) • The results support the suggestion that muscle Note: See the comments on hypermobility in relation ischemia contributes significantly to pain in to trigger points in Chapter 2, and in relation to pro- fibromyalgia, possibly by maintaining central lotherapy in Chapter 7, for different perspectives on sensitization/disinhibition. From previous studies, it chronic low back pain patients (Moseley et al is concluded that fear of movement (‘kinesiophobia’) 2004). A central sensitization has taken place, cognitive combination of physical (see below) and psychologi- behavioral treatment strategies (i. All patients had a posi- exercise used to diminish avoidance behavior tive outcome (Robb et al 2006). Clinical experience suggests useful alternative to the cognitive behavioral that anger can be associated with a lack of approach. Cancer patients that fluctuations in symptoms are avoided often fear a recurrence of their disease (Ahles (stabilization phase). The pacing therefore, be extremely frightening for cancer approach slowly moves towards inclusion of patients. Additional misconceptions and heightened anxiety in hydrotherapy, acupuncture and nutritional approaches many patients. The comorbidity of psychological and physical Six-week multidimensional intervention health problems in chronic illness is well documented, and it is now widely acknowledged that the manage- During the 6-week multidimensional intervention ment of chronic pain requires approaches that address (exercise, massage, relaxation, visualization and all aspects of the pain experience, such as the sensory, behavioral methods) for side-effect symptoms of affective and cognitive dimensions. Physical training of the causes of her pain; confusion over comprised three components: warm-up explanations and advice given to her. Treatment plan: Introduction of an exercise Massage could be relaxing, facilitative or regime with walking and pacing of activities therapeutic. Treatment plan: Graded exercise week focused on balance/coordination; program, including stretches and strengthening grounding and integration of the senses. During the 6-week intervention a decrease in the • Clinical finding: Altered posture secondary to scoring for 10 out of the 12 side-effects was noted pain and muscle spasm. Postural advice and correction of muscle The results of the study indicate that 6 weeks of a imbalance; advice on relaxation. As such, the total burden minutes) of pain, including myalgia, arthralgia, paraesthesia • sit-to-stand test (number of repetitions in 1 and other pain was reduced significantly minute) Patients with evidence of residual disease scored higher • arm endurance test (arm outstretched at 90° in some symptoms/side-effects compared with patients abduction and small movements, endurance in without evidence of disease. However, both groups minutes) responded positively to the intervention as indicated • range of movement: flexion and abduction of from the sum of symptoms and side-effect scores. After a 12-week intervention, significant A variety of chronic diseases are associated with pain. A repeated helpful in approaching acute systemic inflammatory measures design was used. The three treatments con- conditions, from the perspective of physical modali- sisted of ice massage, dry-towel massage and pres- ties. The role for physical treatment was evaluated sepa- The author of the research notes: rately for physical therapy and exercise programs. The theorized mechanism Casimiro et al 2002, Robinson et al 2002, Verhagen underlying ice massage is that it is a counterirritant. Ice massage may activate nerve fibers responsible for carrying the sensation of cold to the spinal cord. Although none of the outcome measures (pain, function) neuropathic pain may be exacerbated by cold, allodynia was influenced by the program (Hammond et related to postherpetic neuralgia may be decreased with al 2004). A one-time application of ice or dry- years followed a program of high-intensity towel massage may not have provided enough tactile exercise during 75-minute group sessions twice stimulation to modulate sensory input to the dorsal a week for 2 years. In the The objective of a study by Yurtkuran et al (2007) was intervention group, improvements occurred in to evaluate the effects of a yoga-based exercise muscle strength, aerobic capacity, emotional program on pain, fatigue, sleep disturbance and bio- status and quality of life. Among these patients, 35 followed a breathing retraining, stretching or some other strength training program designed to form of physical activity – can be tailored strengthen the major muscle groups in the appropriately to assist in health enhancement upper and lower limbs and trunk via exercises for most people against gravity or various loads. The patients • hydrotherapy (see Chapter 11), in one form or exercised at home for 45 minutes twice a week. Patients in the of almost all individuals, whatever the current control group performed flexibility and range- level of wellness or illness of-motion exercises. Bone mineral density was forms including tai chi, yoga and breathing/ not significantly improved. No effects on work relaxation approaches (Chapter 9) – are disability or functional ability were noted. The intrinsically naturopathic in that they avoid exercise program had no adverse effects on forcing change, but rather offer the potential disease activity or radiographic progression. Within the framework of choices outlined in this and Conclusion other chapters the tools for achieving these ends are clearly present. All that is required is attention to the The multiple examples of a variety of modalities, reality of the patient’s needs while maintaining aware- many of them offering benefit in treatment of patients ness of the tenets of naturopathic care.

She reports that she has experienced several episodes of palpitations in the past purchase levitra soft in united states online, often lasting a day or two buy levitra soft cheap online, but never with dyspnea like this proven levitra soft 20 mg. On examination, her heart rate is between 110 and 130 bpm and is irregularly irregular, with blood pressure 92/65 mm Hg, respiratory rate 24 breaths per minute, and oxygen saturation of 94% on room air. On cardiac examination, her heart rhythm is irregularly irregular with a loud S1 and low-pitched diastolic murmur at the apex. She has a diastolic rumble and “ruddy cheeks,” both features of mitral stenosis, which is the likely cause of her atrial fibrillation as a result of left atrial enlargement. Because of the increased blood volume asso- ciated with pregnancy and the onset of tachycardia and loss of atrial contrac- tion, the atrial fibrillation has caused her to develop pulmonary edema. Understand the management of acute atrial fibrillation with rapid ventric- ular response. Know the typical cardiac lesions of rheumatic heart disease and the physi- cal findings in mitral stenosis. Understand the physiologic basis of Wolff-Parkinson-White syndrome and the special considerations in atrial fibrillation. The four major goals are (1) stabilization, (2) rate control, (3) conversion to sinus rhythm, and (4) anticoagulation. This may occur spontaneously or after correction of underlying abnormalities, or it may require pharmacologic or electrical cardioversion. Cardioverting the patient back to sinus rhythm, the return of coordinated atrial contraction in the presence of an atrial thrombus, may result in clot embolization, leading to a cerebral infarction or other distant ischemic event. Alternatively, low-risk patients can undergo transesophageal echocardiography to exclude the presence of an atrial appendage thrombus prior to cardioversion. Postcardioversion anticoagulation is still required for 4 weeks, because even though the rhythm returns to sinus, the atria do not con- tract normally for some time. Pharmacologic cardioverting agents, though not as effective, include procainamide, sotalol, and amiodarone. The longer the patient is in fibrillation, the more likely the patient is to stay there (“atrial fibrillation begets atrial fibrillation”) as a consequence of electrical remodeling of the heart. The major complication of warfarin therapy is bleeding as a consequence of excessive anticoagulation. If clinically significant bleeding is present, warfarin toxicity can be rapidly reversed with administration of vitamin K and fresh-frozen plasma to replace clotting factors and provide intravascular volume replacement. Because she has a history of acute rheumatic fever, her mitral stenosis almost certainly is a result of rheumatic heart disease. Rheumatic heart disease is a late sequela of acute rheumatic fever, arising many years after the original attack. The aortic valve may also develop stenosis, but usually in combination with the mitral valve. Almost all cases of mitral stenosis in adults are secondary to rheumatic heart disease, usually involving women. The physical signs of mitral stenosis are a loud S1 and an opening snap following S2. There is a low-pitched diastolic rumble after the opening snap, heard best at the apex with the bell of the stethoscope. Because of the stenotic valve, pres- sure in the left atrium is increased, leading to left atrial dilation and, ulti- mately, to pulmonary hypertension. Pulmonary hypertension can cause hemoptysis and signs of right-sided heart failure such as peripheral edema. Rate control with intravenous digoxin, beta-blockers, or calcium channel blockers is essential to relief of pulmonary symptoms. A portion of ventricular activation occurs over the accessory pathway, with the remaining occurring normally through the His-Purkinje system. If hemodynamically stable, the agent of choice is procainamide or ibutilide, to slow conduction and convert the rhythm to sinus. He reviews the charts of several patients with atrial fibrillation currently taking Coumadin. Which of the following patients is best suited to have anticoagulation discontinued? A 45-year-old man who has normal echocardiographic findings and no history of heart disease or hypertension, but a family his- tory of hyperlipidemia B. A 62-year-old man with mild chronic hypertension and dilated left atrium, but normal ejection fraction C. A 75-year-old woman who is in good health except for a prior stroke, from which she has recovered nearly all function D. The emergency room physician counsels the patient regarding cardioversion, but the patient declines. The early diastolic decrescendo murmur is typical of aortic regurgi- tation, holosystolic murmur at the apex that of mitral regurgitation, and late-peaking systolic murmur at the upper sternal border that of aortic stenosis. Conditions associated with a high risk for embolic stroke include a dilated left atrium, congestive heart failure, prior stroke, and the presence of a thrombus by echocardiogram. The man in answer A has “lone atrial fibrillation” and has a low risk for stroke and thus would not benefit from anticoagulation. If the patient is stable, initial management is ventricu- lar rate control with an atrioventricular nodal-blocking agent, such as digoxin, beta-blockers, diltiazem, or verapamil. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. This page intentionally left blank Case 4 A 37-year-old executive returns to your office for follow-up of recurrent upper abdominal pain. He initially presented 6 weeks ago, complaining of an increase in frequency and severity of burning epigastric pain, which he has experienced occasionally for more than 2 years. Now the pain occurs three or four times per week, usually when he has an empty stomach, and it often awakens him at night. The pain usually is relieved within minutes by food or over-the-counter antacids but then recurs within 2 to 3 hours. He admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine and eating a lot of take-out foods. His medical history and review of systems were otherwise unremarkable, and, other than the antacids, he takes no medications. His physical examination was nor- mal, including stool guaiac that was negative for occult blood. His symp- toms resolved completely with the diet changes and daily use of the medication. Results of laboratory tests performed at his first visit show no anemia, but his serum Helicobacter pylori antibody test was positive.

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Themes under struggle for existence and natural selection purchase 20 mg levitra soft with amex, military discussion will include theory and experiment buy levitra soft 20 mg line, metaphors in the history of public health order genuine levitra soft, the use of styles of research, ethics of experimental work and metaphors of production in medicine, and the com- scientifc publishing, and the impact of social inter- parison of the brain to a computer. This course will examine the impact of colonial and For doctoral candidates and other advanced stu- post-colonial development on patterns of sickness, dents engaged in original research under faculty health, and health care in Africa. What were the range of responses from will explore the various economic and political inter- religious to therapeutic to disease in China? What ests, as well as the cultural assumptions, that have are Chinese acupuncture, moxibustion, and herbal shaped the development of ideas and practices medicine? Who practiced medicine in China; what associated with international health in “developing” did they practice; and how do we know what we countries. Third, their attention is direct- Professor of International Health ed to the patient as a problem, and they are R. They record their refections and structured cine will be assigned to a preceptor who will patient exercises in an online Learning Portfolio. It is particularly small group discussions and further instruction in clinical skills with their college faculty. To ft the interests They are assessed by their preceptors and with and ability of the student, considerable fex- structured observation of clinical skills in the Simu- ibility in the choice of elective program will be lation Center, as well as for their written work and a possible. After completing the An interdepartmental course in the clinical tech- four week course, students will be able to describe niques of patient evaluation. Students working in the factors that render microorganisms virulent and small groups with an instructor from the clinical correlate these factors with disease processes. A differential diagnosis is of infectious diseases and understand how indi- formed. Whereas the major instruction is from Inter- vidual variability impacts manifestations observed nal Medicine, also included is instruction given by on a population level. Students spend This course is a prerequisite for all clinical clerk- 1-2 afternoons per week, usually working in groups ships and ordinarily will be taken between the third of 5 with their college advisor, to learn and gain and fourth quarters of the second year. Its purpose confdence with best practices in doctor-patient is to prepare new clerks for the daily activities of communication, how to obtain, organize, and com- patient care. Through a combination of lectures, municate to colleagues a patient’s medical history, laboratory exercises and small group discussions, and how to perform a multi-system physical exami- students will learn practical aspects of relating to nation. Students will be prepared for participation patients and their families; to provide care accord- in the Longitudinal Clerkship beginning in January ing to diagnostic probabilities and relative priorities; of Year 1. Resources to assist students in learn- to recognize and manage common acute problems; ing include volunteer outpatients, standardized and to order, perform and interpret the results of patients, trained physical exam teaching associ- basic laboratory tests. Medicine—Second, Third and Fourth The small group format provides students with Years multiple opportunities to learn and practice these This required clinical course is repeated each quar- important skills in a safe environment, enriched by detailed feedback, and supplemental practice ses- ter of the academic year and in the summer. Prerequisite for admission is satisfactory comple- The goal of the Longitudinal Clerkship is to inte- tion of the frst two years of the curriculum at Johns grate the learning of basic science and clinical sci- Hopkins School of Medicine. Available four quarters weeks on the medical service of The Johns Hop- and summer (except July). On most of medical decision making and treatment with the these services students work under the supervision assistance of the housestaff team. Students partici- and tutelage of interns, residents, and the admitting pate in teaching attending rounds, house staff work physician. On the hospitalist service, students work rounds, and both student and housestaff focused directly with the attending hospitalist physicians. Medical students These courses generally involve clinical work in a may join the team, take night call with house staff, medical subspecialty. The student participates in obtain histories and perform physical examinations, all clinical activities of the division, including con- gather and integrate laboratory data and pertinent sultations and outpatient clinics; there is a varying information from literature, participate in decision amount of initial evaluation and follow-up of inpa- making, write admission and progress notes, etc. Students are encouraged to follow a few patients The Medicine Core Clerkship is often a prerequisite. Advanced Clinical Clerkships tion on daily morning rounds which are conducted from 8:30-10:30 a. The nursing staff will provide These courses involve direct management of inpa- instruction in critical care skills such as endotrache- tients to a degree expected of interns (hence the al suctioning, management of multiple intravenous common appellation “subinternship’’). Lecture Courses, Tutorials, and Seminars catheters, proper administration of medications These courses have widely varying prerequisites such as antibiotics and pressors, etc. Individual Preceptorship (such as a lumbar puncture) performed with, and Each division has faculty and specialized clinical under the direction of, the house offcers. Available September through June; 3 in clinics and on the wards under the guidance of students. Opportunities exist for clinical inves- tigations of various types, including the study of Prerequisite: Medicine Core Clerkship. There are also opportunities in resident and an attending physician on one of the most divisions for laboratory investigation. The responsibilities are similar of ing on the background and interests of the student, those of an intern on the service, but with fewer he or she may participate in a current investigation patients and with even more direct resident super- or undertake independent investigation using the vision. The student will admit patients in rotation, laboratory and clinical facilities of the department. The student func- tory research in some of the divisions, the student tions as part of a ward team which takes long call may fnd it advantageous to become identifed with every fourth day and short call in-between. Typi- one of these research programs early in his or her cally, the subintern admits one to two patients on medical school career. Advanced Clinical Clerkship in Medi- imaging of coronary atherosclerosis; subclinical cine. Ischemic heart disease, diabetes and heart This course is offered to provide a comprehen- disease. Teaching is centered on patient care endothelial function; diabetic cardiomyopathy; and is supplemented by departmental conferences. Avail- ground in cardiac physiology and hemodynamics is able as arranged through Dr. There are outstanding opportunities for students to participate in basic The student functions as a member of the medical research efforts. Students can productively engage team at the level of an intern, with the close supervi- in research activities dealing with left ventricular sion by the senior housestaff, cardiology fellow, and function, the physiology and biochemistry of isch- attending physician. Experience is gained in: the emic heart disease, the pathophysiology of sudden evaluation and management of critically ill cardiac death, and the pathophysiologic basis of cardiac patient; dysrhythmia diagnosis and management; disease. Advanced Clinical Clerkship in Cardiol- neoplasia; regulation of calcitonin gene ogy. On-call rooms, food tickets, Neuroendocrine and thyroid disease; cellular free parking passes, and a full-service library with mechanisms of addiction. Prerequisites: Medicine Core Clerkship and Clinical Prerequisite: Any Core Clerkship.

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In December 1989 cheap levitra soft 20mg without prescription, three patients appeared at the Breakspear seeking a consultation with Dr Monro order levitra soft 20 mg with mastercard. Their stories formed the basis for the Sunday Express article published in January 1990 order levitra soft online from canada. On the surface, the article appeared innocuous enough but between the closely argued financial lines ran a story about Dr Monro, her capability and her determination to overcharge patients. As the insurance companies began to be affected by the recession, it was inevitable that the axe would fall first on policy-holders who were being treated by alternative and complementary practitioners, especially for such things as allergy. The Sunday Express article articulated the ground plan which the insurance companies had worked out over the two or three years preceding 1990. Consultants in allergy are thin on the ground in England, and those immunologists who have become consultants and can therefore suggest that they are allergy consultants (though they are really not), are in the main tied up with the drug companies and drug company research. In the early days of this attack by the insurance companies on Dr Monro, the focus was upon her training and qualifications. They [the insurance companies] argue that Dr Monro does not meet this criterion [that of being 4 a specialised consultant] although she has worked in the allergy field for many years. Although the article did not mention it, Dr Monro also has Board Examination qualifications from America. The insurance companies refused to accept each consultant she took on, making her practice appear increasingly unreliable. The fact that these hoops put up for Dr Monro to jump through were simply tactical evasions by the insurance companies and orthodox medical practitioners, rather than mechanisms to protect patients, was made clear by the example of Dr William Rea. Dr Rea, a well-qualified thoracic surgeon and eminent clinical ecologist in America, had, in the mid-eighties, applied to the General Medical Council to practise as a doctor in England. Seeing the developing situation with the insurance companies and desperate to safeguard treatment for people suffering from environmental illness, Lady Colfox, the Chairwoman of the Environmental Medicine Foundation, had taken up his case. One reason might have been that enabling Dr Rea to act as a consultant would have given allergy treatment and environmental medicine a new authority and in turn this would have affected the insurance companies. They and other insurance companies did, however, still fight over every case, and always took an inordinately long time to pay out. The insurance companies greeted the advent of the Campaign Against Health Fraud with relief and funds. Here was an organisation made up in the main of professionally qualified individuals, who had the ear of the medical establishment and the pharmaceutical companies. Such an organisation could reinforce the difficult decisions which the insurance companies were having to take. A whole body of supporting professional opinion could be pushed into the public domain. Company decisions to withdraw cover could be justified as part of common professional practice. Many allergy patients have chronic conditions, and certainly those patients who had been chemically sensitised by the use, for example, of sheep dip, or were toxically damaged, had chronic illnesses. The insurance companies wanted out of the whole area of clinical ecology; if claims were to begin coming in for people badly affected by food additives or ambient chemicals, the insurance companies had somehow to distance themselves from them. Throughout late 1989 and early 1990, Dr Monro kept hearing on the medical grapevine that in the opinion of some of the medical advisers to insurance companies, her work was fraudulent. Rumours came back to her that she would end up in court, or before the General Medical Council. Unbeknown to her, Dr Bailey was from the beginning a member of the Campaign Against Health Fraud. Dr Bailey had been a general practitioner in Bristol before his retirement in December 1988. It is impossible to know whether Dr Bailey, in his capacity as medical advisor to an insurance company, ever divulged information about the condition of particular patients to the Campaign Against Health Fraud. There seems little doubt that with regard to the general questions which he raised in correspondence with Dr Monro, Dr Bailey was gathering intelligence. Dr Bailey had been in correspondence with Dr Monro, not only over individual patients, but also over the general question of allergies. On August 7th 1990 Dr Bailey wrote a long letter to Dr Monro containing a review which he had written of the 1990 Conference of the British Society for Allergy and Environmental Medicine, which was held, in association with the American Academy of Environmental 6 Medicine, in Buxton, Derbyshire. He told Dr Monro that he had read the debate on the Environmental Medicine Foundation in Hansard. This last reference is to Sheila Rossall and his question appears to be fishing for information or, at least, provoking comment about her case from Dr Monro. Dr Monro attended another conference in Bristol in July 1990 and Bailey also refers to this in his review of the Buxton conference. I listened to papers on provocation-neutralisation testing and neutralisation therapy and though controlled trials were described I was not impressed by their significance and had difficulty in understanding the underlying mechanism... In conclusion, we should continue to look critically at allergy and environmental medicine. It should be noted that Dr Jean Munro (sic) spoke at a conference in Bristol in early July 1990. She believes that millions of people could be suffering from environmentally induced disorders without knowing it; a failure of breast feeding; pollution in the environment; the addition of chemicals to food, air, water; the injudicious use of drugs have all led to weakening of the immune system. She suggests that 30% of the British population could be suffering from 7 environmental ailments. At no time, during her correspondence with Dr Bailey throughout 1990, did Dr Monro suspect that he was a member of an organisation which had targeted her, and was gathering information which it would use to try to destroy her. The paper was a report of a double-blind study of symptom provocation to determine 8 food sensitivity. The study claimed to find that only 27% of the active injections were identified by the subjects to be allergens from which they experienced symptoms, and 24% of the placebo control injections were identified wrongly as containing allergens. No references are given for practitioners who do use such techniques to diagnose food allergy. The introduction of extraneous and prejudicial material into an apparently academic piece of writing is always a sign that health-fraud campaigners and representatives of vested interests are at work. Of the eighteen who had unconfirmed allergies, seventeen of them, it was suggested, were psychiatrically ill, ten having depressive neurosis, three neurasthenia, and one each having hysterical neurosis, hypochondriacal neurosis, phobic state, and hysterical personality disorder. She has been an advisor to the Dairy Trades Federation and 13 the Milk Marketing Board. It is of course unlikely that Dr Ferguson would have allowed such interests to colour her judgement about food intolerance, which is said by some to be occasionally related to dairy produce. In Britain, Dr Jean Monro and the Breakspear Hospital were to bear almost the entire brunt of the coming attack. In a working-class south London voice, she asked me if I was an investigator; I said I was, sometimes. She said that I had been recommended to her and she would like me to investigate HealthWatch. I met Lorraine, accompanied by her second child in a push-chair, outside a shoe shop. We found our way into the Basildon municipal Leisure Centre, where muzac serenaded unused red plastic chairs and formica-topped tables. From the moment I met her 1 trusted Lorraine Hoskin; she gave the appearance of being a tough working-class mother, fighting with determination to protect her children.