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This chapter discusses the ethnographic future of the Jamaican Maroons. No one can tell how many Kromanti language specialists remain in the Maroon communities in Jamaica. By the late 1970s, there were clear indications that very few among the younger generation were receiving serious training in the Kromanti tradition. Those interviewed for this book are no longer alive. This chapter suggests that the apparent waning of the Maroons' ancestral religion evidences the same kinds of damaging cultural contradictions, bred by colonialism, that linger on in other parts of Jamaica.

Acupuncture is a therapeutic technique that evolved from ancient Oriental theories and practices of medicine. Since the 1970s, it has become increasingly popular in the West as a means of preventing and treating a variety of disorders. In cancer care, it is used to complement conventional management, helping to control cancer symptoms and the side effects of treatment, as well as being used in the supportive care of cancer patients. It is suitable at any stage of the cancer experience, from diagnosis through active treatment, in palliative and end of life care, and to support survivors in re-establishing their lives. This chapter focuses primarily on the use of needling and moxibustion, as used in traditional forms of acupuncture. First, it defines acupuncture and discusses its history as well as modes of action. It also examines the evidence base on the effectiveness of acupuncture in managing cancer pain, chemotherapy-induced nausea and vomiting, breathlessness (dyspnoea), dry mouth (xerostomia), hot flushes and night sweats, anxiety and depression, immune function, and in treating overall well-being. The contraindications of acupuncture are also considered.

A systematic review of the use of complementary and alternative medicine in patients with cancer reported an average use of 31% across thirteen countries, although the range was wide (7–64%). Many patients experience distress following the diagnosis of cancer and wish to pursue methods that they believe might help them to feel more relaxed and in control, as well as minimise treatment side effects. This chapter focuses on three such interventions: relaxation therapy, visualisation, and hypnotherapy. Like drugs, these interventions have indications, contraindications, and cautions. It is important that practitioners are familiar with these before attempting to utilise them for cancer patients. These interventions all share some non-specific factors including a healing ritual, a helping relationship, hope, suggestion, and expectation of change. However, there are a number of important theoretical and practical differences, which are described in this chapter.

This chapter discusses regional nerve blocks. These can only be undertaken in an environment that provides enough facilities for skilled assistance, sterility, equipment, monitoring, appropriate imaging, resuscitation, and aftercare. The chapter examines several regional nerve blocks and the anatomy where these are usually applied; the techniques used; and specific complications, indications, and contraindications.

Chapter 12 contextualizes scientific claims about health benefits and considers evidence of adverse effects. The chapter argues that scientific support for school-based yoga, mindfulness, and meditation is weaker than often claimed and falls short of demonstrating that programs are secular, safe, or superior to alternatives. Low-quality studies report health benefits, using uncontrolled, pre-post designs, or nonactive controls, with small sample sizes, and high risk of bias, including expectation bias, researcher allegiance, publication bias, and citation bias; higher quality studies show less efficacy. Scientific evidence is not equivalent to evidence of secularity; research studies report that meditation in religious contexts, as well as prayer and Bible reading, can benefit health and activate specific brain regions. Some participants report challenging experiences with meditative practices, including anxiety, depression, physical pain, reexperiencing of traumatic memories, anger, and suicidality. Meditative practices may be contraindicated for participants with a history of trauma, PTSD, addiction, psychosis, anxiety, depression, or suicidality. Research shows that alternatives, such as aerobic exercise, math, music, nutritious food, or different behavioral therapies, can produce comparable benefits, including training the brain through neuroplasticity. Yet marketers rarely disclose risks of adverse effects, screen for contraindications, or provide information about alternatives.

The diagnoses shown in bold in Figure 18.1 are all surgical emergencies that you must exclude as you clerk the patient. In women, you should consider gynaecological causes, e.g. ectopic pregnancy, ovarian torsion (you can of course narrow these down depending on whether the woman is of childbearing age or not). Also, bear in mind that other abdominal pathology can occasionally present as flank pain (e.g. pancreatitis, diverticulitis, appendicitis). You should ask the standard array of questions about the pain—remember the mnemonic SOCRATES: Site: Where is the pain, and has it always been there? Is it unilateral or bilateral? Kidney stones are almost always unilateral, but the location of the pain may radiate from loin to groin. Often they start with a vague discomfort that is ignored until it becomes a severe pain. Onset: Any trauma or other trigger, or spontaneous? Gradual or sudden? Trauma may lead to musculoskeletal pain or internal bleeding. Character: Is the pain colicky or constant? Is it sharp or dull? Ureteric stones give a colicky (waxing and waning) pain because of periodic spasms of the ureteric smooth muscle walls trying to dislodge the blockage. A constant pain is more consistent with a stone lodged in the kidney, which does not periodically contract (‘vermiculate’) like the ureters, or an inflammatory cause. Musculoskeletal pain is more typically an ache, while nerve impingement causes shooting pains. Radiation: Does the pain radiate to the groin (typical of ureteric pain)? Does it radiate down the leg (typical of lumbar nerve root pain)? Alleviating factors: Does anything make the pain better, e.g. a given posture, eating/drinking, any medications, etc.? Timing: How long has the pain been present? Musculoskeletal back pain can last many weeks, whereas a leaking abdominal aortic aneurysm (AAA) is unlikely to persist for more than a day without resolution, one way or another. Exacerbating factors: Does anything make the pain worse? Patients with peritonitis (e.g. due to a perforated peptic ulcer) are very sensitive to movement. Severity: How severe is the pain (e.g. on a scale of 1–10)? Kidney stones are said to be excruciatingly painful, comparable to childbirth.

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Most rhegmatogenous retinal detachments are blinding disorders unless they are successfully repaired. They were regarded as incurable until the seminal work of Jules Gonin in the 1920s, when an anatomical success rate approaching 50% was first described (see Chapter 1). Anatomical results for routine retinal detachments slowly improved through several decades, reaching the current 85%–90% single-operation success figure for scleral buckling by the 1980s. Unfortunately, a similar improvement in visual results has not occurred because of the profound influence of preoperative macular detachment. Scleral buckling, once the sole standard of care for uncomplicated cases, has become much less popular worldwide with the development of alternative options starting in the mid 1980s. The most enduring of these are pneumatic retinopexy (PR) (described in Chapter 8) and vitrectomy (described in Chapter 9). Vitrectomy was originally reserved for complicated detachments but became popular for more routine cases as experience and equipment improved. Today, particularly in the United States, scleral buckling, PR, and vitrectomy are standards of care that are widely employed in the management of “routine” or “uncomplicated” retinal detachment, but how frequently each is used varies among different demographic groups. For instance, the popularity of PR varies by geographical location and scleral buckling appears less popular in the hands of relatively young vitreoretinal specialists. It can be useful to discuss objective clinical criteria that may favor one technique over another. Demarcation, scleral buckling, PR, vitrectomy, and vitrectomy plus scleral buckling have relative indications and contraindications (Table 10–1), as well as limitations and complications. In this brief chapter, clinical factors that may influence the choice of one technique over another, for the types of cases in which scleral buckling, PR, and/or vitrectomy are neither mandatory nor contraindicated, are discussed. However, it appears clear that we will never universally agree on the “best” operation for a given case, just as a single ice cream flavor will never be favored by all. There are several relatively common types of uncomplicated retinal detachments (Table 10–2), as well as numerous variables associated with all of them (Table 10–3). Management of retinal detachments with each specific technique is described in Chapters 7, 8, and 9.

The popular images of electroshock presented in the media reflect practices that were discarded more than 40 years ago. The films One Flew Over the Cuckoo’s Nest and A Beautiful Mind portray imaginative Hollywood images—not reality. The dramatic scene of a pleading patient dragged to a treatment room, forcibly administered electric currents as his jaw clenches, his back arches, and his body shakes while being held down by burly attendants or by foot and wrist restraints, is false. Patients are not coerced into treatment. They may be anxious and reluctant, but they come willingly to the treatment room. They have been told why the treatment is recommended, the procedures have been explained, and many have seen DVD or video images of the procedures. Each patient has consented to the treatment in writing, and in many instances, family members have also agreed. Understandably, the patient may be hesitant about the first treatment. He has seen those movies, so the procedures are explained again, and, except for feeling a needle placed in his vein and electrodes and measuring devices attached to his body, the patient is unaware of the treatment as it occurs. One patient described his treatment this way: “It is a nonentity, a nothing. You go to sleep, and when you wake up, it is all over. It is easier to take than going to the dentist.” Many patients ask to be treated early in the morning so that they can return to the day’s activities as soon as possible. It is not uncommon for patients to reassure family members about the procedure. Doctors frequently ask an experienced patient to explain the procedures and the discomforts to a candidate; patients undergoing ECT have proved to be its best advocates. A consent form, voluntarily signed by each patient, is a necessary part of electroconvulsive treatment in the United States. Such a consent procedure is uncommon in psychiatric practice, and was developed to address concerns about abuse at a time when public distrust of governmental authority was widespread and had affected the physician-patient relationship. In most venues, doctors accept the patient’s cooperation with medication treatment and psychotherapy as consent.