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Causes are as follows: r Obstruction: Gallstones buy loratadine 10mg with visa, biliary sludge purchase loratadine online from canada, carcinoma of the pancreas loratadine 10mg visa. Introduction to the pancreas r Drugs/toxins: Alcohol, azathioprine, steroids, diuret- The pancreas has two important functions: the produc- ics. Translocation of gut pancreatitis bacteria can result in local infection and septicaemia. Within 48 hours of admission Shock may result from the release of bradykinin and Age >55 years prostaglandins, or secondary to sepsis. Haemorrhage may cause Grey Turner s sign, which is bruising around the left loin and/or Cullen s sign, bruising around the umbilicus. The pancreas appears oedematous with grey-white Other investigations are required to assess the sever- necrotic patches. Bacterial infection leads to inamma- ity and to monitor for complications: full blood count, tion and pus formation. Healing results in brosis with clotting screen, urea and electrolytes, liver function tests, calcication. Complications In the most severe cases there is systemic organ failure: Management r Cardiovascularsystem:Shock(hypotension,tachycar- The early management depends on the severity of the dia, arrhythmias). Patients require careful uid balance zymes walled off by compressed tissue), pancreatic using central venous pressure monitoring and uri- abscesses (which may contain gas indicating infection nary catheterisation to allow accurate urine output withgas-formingbacteria)andduodenalobstruction. Prophylactic Investigations broad-spectrumantibioticsaregiventoreducetherisk When supportive clinical features are present the diag- of infective complications. Ascites and persistent obstructive jaundice with conservative management require laparoscopic may occur. Prognosis Investigations Pancreatitis is a serious condition: overall mortality is Serum amylase uctuates, but may be moderately raised 10%. Endoscopic retrograde cholangiopancreatography mayshowscarringoftheductalsystemandevenstonesin the pancreatic duct. Magnetic resonance cholangiopan- Chronic pancreatitis creatography is increasingly being used. Denition Chronic pancreatitis is an inammatory condition that Management results in irreversible morphological change and impair- Precipitating factors especially alcohol need to be re- ment of exocrine and endocrine function. Adequate analgesia is required, thoracoscopic splanchnicectomymayberequiredinrefractorypainnot Age associated with main pancreatic duct dilatation. Surgical M > F techniques include sphincteromy or sphincteroplasty, partial pancreatectomy or opening the pancreatic duct Aetiology/pathophysiology along its length and anastomosing it with the duodenum Two patterns of chronic pancreatitis are seen, a chronic or jejunum. Total pancreatectomy can be carried out, relapsing course with recurring acute pancreatitis and with replacement oral pancreatic enzymes and insulin. Risk factors includealcoholabuse,hereditarypancreatitis,ductalob- Tumours of the pancreas struction (e. Hy- percalcaemia, hyperlipidaemia and congenital pancre- Denition atic malformations are recognised associations. Clinical features Incidence Patients may present with an acute episode of pancre- 10 per 100,000 per annum and rising. Late com- plications include impaired glucose tolerance, diabetes Age mellitus and malabsorption (steatorrhoea) associated Mainly >60 years. Aetiology There appears to be some familial clustering and hence Investigations it is suggested that genetic susceptibility may play an There are no useful tumour markers or pancreatic func- important role. Specic inherited risks include famil- tion tests for diagnosis, which must be histological. Mosttumoursdevelop intheheadofthepancreasandthesetendtopresentearly ducts and may also be used for intervention. Clinical features Pancreatic cancer is associated with several clinical syn- Management dromes: Surgical resection offers the only chance of cure, but only r One third of patients present with painless obstructive about 10 15% of patients are suitable for radical surgery jaundice, i. Chronic epigastric pain radiating to the back similar to chronic pancre- denectomy with block resection of the head of pan- atitis develops in most patients at some stage. There is signicant orrhoea is common and failure to absorb the fat- perioperative morbidity and mortality. Stents of the bile duct and/or duodenum tend to become blocked and Macroscopy/microscopy have to be replaced. Most tumours are moderately differentiated The prognosis is extremely poor with an overall 5-year adenocarcinoma with a prominent brous stroma. Radiolabelled octreotide (a somato- statin analogue) can be used for localisation of the primary tumour and detection of any metastases. Insulinoma: Ausually benign islet-cell tumour that may r Several options are available for the treatment of occur in the pancreas or at ectopic sites causing the metastatic neuroendocrine tumors including oc- hypersecretion of insulin. There may be gradual in- treotide, interferon,chemotherapy and hepatic tellectual and motor impairment with insidious per- artery embolisation. Severe attacks of hypoglycaemia can Glucagonoma: This is a very rare tumour of the islet cells produce sweating, palpitations, tremulousness and a of the pancreas which is often asymptomatic. Patients maypresentwithnecrolyticmigratoryerythema,painful may present with a hypoglycaemic coma. Treatment is by resection where possible, or sys- centrations of insulin may be helpful, endoscopic ul- temic treatment as for insulinoma. Symptoms r Associated symptoms include nausea, vomiting, frank haematuria (blood in the urine). Loin pain Loin pain is associated with fever, and loin tender- ness is strongly suggestive of infection of the kidney Denition (pyelonephritis). Theremaybenauseaandvomiting,but Loin pain or ank pain is pain felt unilaterally or bilat- lower urinary tract symptoms (such as stinging, burning erally in the back, below the twelfth rib. It has two main onpassingurineorurinaryfrequencymaybeminimalor causes: obstruction and inammation. Theclassicformof loinpainisfromobstructiontothe Dysuria outow of urine, usually caused by a renal stone (often called renal colic, although the pain may not always be Denition colicky). Dysuriaisthesensationofburningorstingingonpassing r Site:The pain is usually unilateral, as bilateral renal urine. Blood can come from anywhere within the urinary r Associated symptoms of urgency and dysuria, usually tract, from the glomeruli, down to the urethra. Pink with low volumes passed each time suggest a urinary tingedurineatthestartofmicturition,whichthenclears, tract infection. The beginning of ow after ini- there is either haemoglobin or myoglobin in the urine, tiation should be prompt if delayed, this is called such as occurs in rhabdomyolysis. Certain drugs (such as hesitancy, and dribbling more than a few drops after rifampicin) and beetroot ingestion can make the urine the end of micturition is called terminal dribbling. Poor appear orange, pink or red, but the dipstick test will be ow, hesitancy and terminal dribbling are characteristic negative (see Table 6. Darkurinedoesoccurincon- Volume: The volume of urine passed is usually about junction with pale stools in obstructive jaundice. A high fore sweat) and those too busy to drink enough uid, concentration of phosphate in the urine is quite com- this volume can often drop to 700 800 mL. Oliguria is reduced urine excretion, often used asatermwhen<20 or 30 mL/hour is passed. This should be treated, then tioning kidney (which will, if not rapidly treated, go on urine re-tested to ensure the haematuria has cleared.

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Pharmaceutical companies buy loratadine 10 mg online, as the innovators There is a social contract between pharmaceutical and producers of life-saving medicine loratadine 10 mg cheap, act early companies and the people who need their prod- in the value chain loratadine 10mg. Our research suggests that many people in the impact on access can be huge with signif- the industry are committed to fulflling this con- cant savings for healthcare budgets, and of course, tract. But progress is slower than many of us in terms of improving human life and wellbeing. At the Access to Medicine Foundation, we have been tracking the world s largest research-based pharmaceutical companies for ten years now, look- ing at how they bring medicine within reach of people in low- and middle-income countries. Iyer held their top spots over the years by asking the Executive Director right questions, reviewing their paths and challeng- Access to Medicine Foundation ing themselves to keep improving, against a chang- ing backdrop of stakeholder expectations and competing priorities. For and diagnostics more accessible in low- and mid- the 2016 Index, the weight of the performance pillar was increased to dle-income countries. This process ensures that Index metrics express what Methodology Framework stakeholders expect from pharmaceutical companies. Once data is sub- 10 Market In uence & Compliance mitted by the companies in scope, it is verifed, cross-checked and sup- plemented by the Foundation s research team using public databases, 20 Research & Development sources and supporting documentation. The research team scores each company s performance per indicator, before analysing industry progress in key areas. For example, in pricing, the Index examines whether com- 10 Capacity Building panies price products fairly in the countries with the greatest need for those specifc products. In R&D, it looks at whether companies are 10 Product Donations developing products that are urgently needed, yet ofer little commer- cial incentive. They include best and the industry has performed across pricing, licensing and donations; Performance and Innovation. It sets out the Governance & Compliance, and analysis of the company s portfo- drivers behind changes in ranking; how closer integration of these lio and pipeline for high-burden the reasons why companies place policy areas can beneft access to diseases. ThisTo ensure afordability, companies needsocio-economic factors Product Donations 1 (2014). Thisaccounts for 39% of its relevant portfo-41 products with equitable pricing strat- factors. The 2014 Index identifed eightdepends on multiple socio-economicsocio-economic factors that companies Ranking by technical areaManagement4. Together, the strategies target 35%of the priority countries for the diseases the Index analysed which companiestake these eight factors into account,consider when setting prices. Together, strategies for these products products, accounting for 49% of its rel-evant portfolio. Together, the strategiestarget 31% of the priority countries for fed during methodology development. It has seven mar-keted products with equitable pricing marketed products), AstraZeneca is thecompanies (those with fewer than 50the diseases in question. Companies on higherrankings tend to engage in more struc- 43 96Johnson & JohnsonEisai Co. It considersthe following factors most frequently: tured donation programmes, of abroader scale and scope. True needs-based pricing is limited a greater level of responsibility withof donation programmes. It leads in product donations and in applyingprojects that target independently identifed, high-priority diseases. Sales in emerging markets accountogy, immuno-infammation, respiratory and rarefor approximately 25% of total sales. More products have equitable pricing ered for multiple population segments of afordability in these markets. Such strategies arethese still respresent a third of all 850 products on the market, and their use come countries), Only 44 (5%) products out of 850 have a strategy thatmeet the key criteria looked at by the Index and applies in even one prior-ity country*. Its lead-ership is refected in many areas: it has clearly committed to equitable pricing strategies, and is a leader in voluntary licens-ing and capacity building. More products than in 2014Pharmaceutical companies report 850products on the market for high-burden within a country). As in 2014, approx-imately a third of products with equi-table pricing have intra-country strate- analysis will continue to shape priceadjustments for respiratory and car-diovascular disease products in these particularly important where inequality is high (e. Many products have multiple strategies, gies, despite their being seen as particu-larly important for increasing afordabil- markets. Programmes for communica-programmes being expanded and 1415 1117 Gilead Sciences Inc. It has a wide range Its diverse pipeline targets all four disease cat-egories in scope. The diseases with the mostequitably priced products are: ischaemic lack of universal health coverage. This isity where there is high socio-economicinequality, limited public fnancing and a to maximise patient access and aforda-bility. One of its key roles is to integrateExcellence, which has a regional team cifc target groups and on adapting to asingle country context. Change by thesethe 2016 Index used tougher meas- processes for ensuring compli-ance. All sevengency relief and through structuredad hocfor emer- and has put standardised procedureshas increased the scale and scope ofits structured donation programmes, to further foster innovation in this area, and tosystems. Together these cover all disease categories, with part-ners including Fiocruz, Johnson & Johnson and Monash University. Pipeline by stage of development Innovative medicines and vaccines and/or as frst-line treatments: e. For example, they invest inR&D for urgently needed products,even where commercial incentives (albeit those considered key forwork applies to few products10th place. Its solid access frame- and rose from 20th place, andlaunched a new access strategytal. Johnson & Johnson runs the largesttured donation programme that works tracking the reception of donated prod-ucts and requiring regular reports frompartners on results and outcomes of the There are seven companies in theing and auditing requirementsMiddle group lacks stringent monitor- dle-income countries, depending on the local(distributors, wholesalers, etc. Roche has been included in the Index as it can also improve access in areas**Roche declined to provide data to the 2016 Access to Medicine Index. It referred to thefact that oncology, which is not in the Index scope, is its main focus for improving access ucts target just three priority countries. Opportunities missed as there is no equitable pricing strategy(all products and diseases) period of analysis. Eisai has commit to ensuring donation activities Publish information about products registra-tion status. Critically, these yet have room to deepen engage- and withstood closer scrutiny: advances in other measures, with companies show needs-orienta- ment in access to medicine. There the 2016 Index used tougher meas- new access initiatives and strong tion, matching actions to externally have been two signifcant shifts in ures than in 2014. Change by these processes for ensuring compli- identifed priorities in the access this group. AstraZeneca joins the top Bayer, which lost ground as others were not sufcient to avoid being support commercial objectives, ten, with an expanded access strat- improved.

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The freestanding character of the medical profession in Hippocratic term s is underscored as well in The Art purchase loratadine no prescription, which says that m edicine is the only art which [the] states have m ade subject to no penalty save that of dishonour buy loratadine cheap. loratadine 10 mg sale.. The Hippocratic Oath and Contem porary Medicine 111 Miles sees in the concept of a medical guild a positive emphasis on the wis- dom of older physicians: first, older physicians know better the speculative nature of medical innovations and have learned how to put into practice what has been learned in the labs. In other words, they have a better under- standing of the connection between theory and the clinical practice. In Miles opinion, not enough attention has been given to reform or abolition of education by rep- resentatives of drug companies (Miles, 2004, p. These are important issues that need careful attention but cannot be addressed in this paper. In short, Miles contends that this inter-generational dimension in medical practice reflects the moral obligation to consider one s teachers as one s parents and a way to secure the trust of patients and of public opinion. The Commitments of the Physicians The Oath rehearses a set of obligations that mix together both moral con- cerns and religious interests in purity. Above all, however, the physician must restrain from all intentional wrong-doing and harm. Miles remarked that in W estern modern societies physicians and health care professionals played a particular role in society which assumes a special ethical contract for their conduct, which is often expressed in the adage Prim um non noc- 8 ere (Miles, 2004, pp. W hat the exact nature of this contract is and the basis for its obligatory dimension is not stipulated, nor clearly articulated by Miles. It is certainly the case that patients and society in general expect high standards of care for which the aim is the recovery and well-being of the patients. Some physicians will see abortion as moral wrong in the majority of the cases while others will consider the abortion of a fetus resulting from rape as an act of courage. In fact, Miles interprets the vow to keep the ill from injustice as a particular commitment to a specific view of the good. He does this so as to develop a critique of the health care delivery system in United States in which more than forty million Americans [who] do not have public or private health insurance for more than one year at a time, [a] fifth of these 112 F. W hile this is true that the medical profession is far from being united as to social concerns, particularly as to a universal health care system, it is worth noting that the introduction of the Medicare-Medic- aid Act (1965 1966) during the Kennedy and Johnson administrations (1961 1969) is precisely the source of the dependence of medicine on social institutions, thus rendering it quite un-Hippocratic. The inauguration of the managed care era transformed the medical profession on two levels, one of them being the dependence on those institutions that are often criti- cized for limiting health care benefits. The threat of malpractice lawsuits and the erosion of public trust in the medical profession due to the economic factors influencing health care delivery are important issues in contemporary reflections on the medical profession that damage to a certain extent the image of the medicine. Yet, the profound transformation of American medicine at the socio-economic level through which medicine became dependent on institutions (i. A cogent criticism of contem p orary m edicine m ust take into account this crucial elem ent which, as we will see, recast the idea of medicine as a profession. Among others, Miles attempts a criticism of the American approach to the provision of health care resources by arguing that the Hippocratic Oath, as well as the Hippocratic tradition, imply an obligation to establish a uni- versal health care. First, Miles argues from the Hippocratic injunc- tion to keep the ill from injustice to an obligation in social justice. The Greek term dik, as used in the Hippocratic corpus and generally in Greek thought, had no implications of a claim regarding distributive justice. Rather, as Ludwig Edelstein remarks, the physician obligation is towards his patient and not society per se. Second, from the fact of the matter that all industrialized societies except the United States provide for an all-encompassing health care system and also revere the Hippocratic tradition, it does not follow that they do so because of the Hippocratic tradition and its moral commitments. Granted this is a complicated issue, but it is not one that Miles estab- lishes convincingly, but which he is required to establish unless he wishes simply to hold that the establishment of a right to certain services without showing the actual benefit of that right is sufficient to secure his critique. Last but not least, he does not address the circumstance that all industrial- ized countries with universal health care coverage are more generally going a financial crisis and are as a result in the process of limiting their coverage and increasing the role of the private sector. This has particular relevance in that the Hippocratic Oath and Greek medicine were lodged in a market economy that eschewed governmental regulation of health care (on the concept of civic physicians in Ancient Greece see Nutton, 1992, esp. Finally, one could argue that while it is certainly regrettable ( unjust according to Miles) that some Americans do not have access to health care at a level higher that in many European countries, it must be emphasized that a universal health care system would likewise create injustice of various sorts. For instance, Canada prohibits already from buying better basic care, independently of one s ability to pay. The basis for a universal coverage and the notion of the right to health care seems then rather difficult to support. Not only does Miles fail to demonstrate how a universal coverage and the notion of the right to health care would be possible but he also did not rec- ognize the politically charged tone of this arguments for a universal health care system. Curiously Miles ignores his political assumptions but is eager to stress that Today, all economically developed nations whose healers claim descent from the Hippocratic tradition view universal access to affordable health care as a moral obligation of their health care system every developed nation except the United States. I believe that physicians could embrace a commitment to working for affordable universal health care as exemplifying the principle from what is to their harm or injustice I will keep them. His claim that the legal and ethical norms for these [medical] activi- ties and many other are governed by an implicit or explicit pact between physicians and society (Miles, 2004, p. The difficulty is that Miles does not develop the moral arguments needed to show that 114 F. Instead of a moral argument, he substitutes the dubious historical claim that the Hippocratic Oath and the professional tradition it supports requires such provision. Medicine as a Profession The Oath ends with the sanction that follows if the physician is not faithful of the covenant: If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite to all this be my lot. Oaths imply not only the requirement to keep personal promises but like- wise are a social institution which establish the rules for social interaction between individuals (i. Many scholars, Miles included, recognize that a position supporting the view that certain values and obligations are intrinsic to the practice of med- 12 icine (called the internal morality of medicine ) is problematic due the various moral visions inherent of our pluralistic society. Miles adopts a mid- dle way position arguing that the Oath reflects a blended position in which society s time-tested moral views are the proper measure of the ethics of medicine (Miles, 2004, p. Thus, Miles accepts that the moral standards The Hippocratic Oath and Contem porary Medicine 115 of medicine must be reevaluated in the light the historical development of society but likewise suggests that the Oath ought not to be regarded as an old relic relevant for past medical practitioners of Ancient Greece. The Oath, he claims, can still teach us one medical ethic among competing moral systems. It is only insofar as one is able to understand (thus, the necessity to study the Oath) how the Oath might have spoken to its own culture that one will be able to see how relevant it is for his or her own. This begs the question as to know whether everyone will recognize the moral values and obligations described in the Oath as relevant for contem- porary medicine. As I have emphasized, scholars such as Miles who regard the Hippo- cratic Oath simply as symbolic discount the full force of its power as a doc- ument to direct professional conduct. Thus although Greek medicine recognized and emphasized the idea of a guild/profession, it appears that it does not correspond to today s model of medical practice. Gone too are the simple certainties of an ethic based entirely on what the doctor thinks is good for the patient, and with it also any acquaintance with Hippocratic morality outside the Oath and a few phrases such as primum non nocere... Professors of medical history are giving way to medical ethicists as the keepers of the medical con- science, or are themselves turning to history of ethics as a way to ensure the relevance of their own discipline in a modern medical school. The reasons are multiple and they deserve a more careful examination than what I will be able to accomplish in this article. However, it is crucial to locate the development of medicine in its proper context, par- ticularly how American medicine went from the status of guild power between 1930 and 1965 to its decline in power from 1970 to 1990 (Krause, 1996).

This life-span is brought into existence with the prenatal check-up purchase loratadine paypal, when the doctor decides if and how the fetus shall be born order generic loratadine, and it will end with a mark on a chart ordering resuscitation suspended generic 10mg loratadine free shipping. Between delivery and termination this bundle of biomedical care fits best into a city that is built like a mechanical womb. The old are the most obvious example: they are victims of treatments meted out for an incurable condition. Boy-scout training, good-Samaritan laws, and the duty to carry first-aid equipment in each car would prevent more highway deaths than any fleet of helicopter-ambulances. Those other interventions which are part of primary care and which, though they require the work of specialists, have been proved effective on a population basis can be employed more effectively if my neighbor or I feel responsible for recognizing when they are needed and applying first treatment. For acute sickness, treatment so complex that it requires a specialist is often ineffective and much more often inaccessible or simply too late. After twenty years of socialized medicine in England and Wales, doctors get to coronary cases on an average of four hours after the beginning of symptoms, and by this time 50 percent of patients are dead. The demand for old-age care has increased, not just because there are more old people who survive, but also because there are more people who state their claim that their old age should be cured. Many more children survive, no matter how sickly and in need of a special environment and special care. But in rich countries the life expectancy of those between fifteen and forty-five has tended to stabilize because accidents143 and the new diseases of civilization kill as many as formerly succumbed to pneumonia and other infections. Relatively more old people are around, and they are increasingly prone to be ill, out of place, and helpless. No matter how much medicine they take, no matter what care is given them, a life expectancy of sixty-five years has remained unchanged over the past century. Medicine just cannot do much for the illness associated with aging, and even less about the process and experience of aging itself. This minority is outgrowing the remainder of the population at an annual rate of 3 percent, while the per capita cost of their care is rising 5 to 7 percent faster than the over-all per capita cost. As more of the elderly acquire rights to professional care, opportunities for independent aging decline. Simultaneously, as more of the elderly are initiated into treatment for the correction of incorrigible impairment or for the cure of incurable disease, the number of unmet claims for old-age services snowballs. She will thus be marginally medicalized by two sets of institutions, the one designed to socialize her among the blind, the other to medicalize her decrepitude. As more old people become dependent on professional services, more people are pushed into specialized institutions for the old, while the home neighborhood becomes increasingly inhospitable to those who hang on. Only the very rich and the very independent can choose to avoid that medicalization of the end to which the poor must submit and which becomes increasingly intense and universal as the society they live in becomes richer. From weak old people who are sometimes miserable and bitterly disappointed by neglect, they are turned into certified members of the saddest of consumer groups, that of the aged programmed never to get enough. But while it has become acceptable to advocate limits to the escalation of costly care for the old, limits to so-called medical investments in childhood are still a subject that seems taboo. The engineering approach to the making of economically productive adults has made death in childhood a scandal, impairment through early disease a public embarrassment, unrepaired congenital malformation an intolerable sight, and the possibility of eugenic birth control a preferred theme for international congresses in the seventies. Life expectancy in the developed countries has increased from thirty-five years in the eighteenth century to seventy years today. This is due mainly to the reduction of infant mortality in these countries; for example, in England and Wales the number of infant deaths per 1,000 live births declined from 154 in 1840 to 22 in 1960. While in gross infant mortality the United States ranks seventeenth among nations, infant mortality among the poor is much higher than among higher-income groups. In New York City, infant mortality among the black population is more than twice as high as for the population in general, and probably higher than in many underdeveloped areas such as Thailand and Jamaica. It would be equally reckless to claim that those changes in the general environment that do have a causal relationship to the presence of doctors represent a positive balance for health. Although physicians did pioneer antisepsis, immunization, and dietary supplements, they were also involved in the switch to the bottle that transformed the traditional suckling into a modern baby and provided industry with working mothers who are clients for a factory-made formula. The damage this switch does to natural immunity mechanisms fostered by human milk and the physical and emotional stress caused by bottle feeding are comparable to if not greater than the benefits that a population can derive from specific immunizations. For instance, in 1960, 96 percent of Chilean mothers breast-fed their infants up to and beyond the first birthday. Then, for a decade, Chilean women underwent intense political indoctrination by both right-wing Christian Democrats and a variety of left-wing parties. By 1970 only 6 percent breast-fed beyond the first year and 80 percent had weaned their infants before the second full month. But medicine does not simply mirror reality; it reinforces and reproduces the process that undermines the social cocoons within which man has evolved. Preventive Stigma As curative treatment focuses increasingly on conditions in which it is ineffectual, expensive, and painful, medicine has begun to market prevention. Along with sick-care, health care has become a commodity, something one pays for rather than something one does. The higher the salary the company pays, the higher the rank of an aparatchik, the more will be spent to keep the valuable cog well oiled. Maintenance costs for highly capitalized manpower are the new measure of status for those on the upper rungs. The medicalization of prevention thus becomes another major symptom of social iatrogenesis. It tends to transform personal responsibility for my future into my management by some agency. Usually the danger of routine diagnosis is even less feared than the danger of routine treatment, though social, physical, and psychological torts inflicted by medical classification are no less well documented. Diagnoses made by the physician and his helpers can define either temporary or permanent roles for the patient. In either case, they add to a biophysical condition a social state created by presumably authoritative evaluation. No one is interested in ex-allergies or ex-appendectomy patients, just as no one will be remembered as an ex-traffic offender. Professional suspicion alone is enough to legitimize the stigma even if the suspected condition never existed. The medical label may protect the patient from punishment only to submit him to interminable instruction, treatment, and discrimination, which are inflicted on him for his professionally presumed benefit. It turns the physician into an officially licensed magician whose prophecies cripple even those who are left unharmed by his brews. The mass hunt for health risks begins with dragnets designed to apprehend those needing special protection: prenatal medical visits; well-child-care clinics for infants; school and camp check- ups and prepaid medical schemes. The United States proudly led the world in organizing disease-hunts and, later, in questioning their utility. This assembly-line procedure of complex chemical and medical examinations can be performed by paraprofessional technicians at a surprisingly low cost. It purports to offer uncounted millions more sophisticated detection of hidden therapeutic needs than was available in the sixties even for the most "valuable" hierarchs in Houston or Moscow. At the outset of this testing, the lack of controlled studies allowed the salesmen of mass-produced prevention to foster unsubstantiated expectations.

Stool samples were collected and studied for enteric pathogens by standard procedures order loratadine 10mg with visa. The causative agents identified as localized enteroadherent factor positive Escherichia coli serotype 0114: H2 generic 10 mg loratadine with mastercard. The deficit of sodium cheap loratadine express, due to an increased renal loss of this ion, leads to a fall in extracellular fluid plasma volume, resulting impaired kidney function and finally to peripheral circulatory failure. In the initial stages, the urine is alkaline, the excess of bicarbonate being excreted in association mainly with sodium. As the resultant sodium deficit develops there is renal conservation of this ion, the sodium in the urine being replacd by potassium and hydrogen, with the result that in the later stages of the condition, there is the apparent paradox of an acid urine in the face of severe extracellular alkalosis. A potassium deficit, usually of moderate dimension, develop partly from the loss of potassium in the vomit and to a greater extent from the loss of urine, its main importance is that is excerbate the extracellular alkalosis but it is not the main cause of this feature of disturbance. The most important electrolyte change in patient in this study is the loss of chloride and hydrogen in the gastric content. The fall in plasma sodium concentration is due to loss in the vomit and mainly in the urine. There is a close reciprocal relationship between the plasma chloride and bicarbonate concentration. Since none of the patients in this study showed neither parodoxical acciduria or circulatory failure, all the patients in the study seemed to seek medial advice in their early stage of the disease. Two areas of Lamadaw Township were selected for study and designated as ward "A" and ward "B" Although these two wards are within the same township, the environmental conditions of the two wards are not the same. The residents of ward "A" have satisfactory living space, abundant available safe water supply and sanitary sewage disposal system. The residents of ward "B" do not have satisfactory living space; the available water supply is insufficient and the sewage disposal system is unsatisfactory. Moreover the living standard and educational and social status of the residents of the two selected wards are unequal, being higher for the residents of ward "A". The results so obtained were from direct microscopic examination of stool specimens. Most probably a higher prevalence rate will be obtained if the specimens are examined 72 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar by concentration methods. The intestinal parasites commonly encountered were Ascaris lumbricoides and Trichuris trichiura. Limitations due to the time factor are presented and a more extended survey for intestinal parasites is recommended. The general, residents of ward, a live in better environmental conditions and most have a higher financial income. The method use for examination of stool specimens was direct microscopic examination. The intestinal parasites most commonly encountered in both wards were Ascaris lumbricoides and Trichuris trichiura. Most of the children were malnourished although it is not significantly due to over-crowding. Most of them come from low social class with poor sanitary fcailities and unhygeinic water supply. Beacuse 75% of cases come from urban and periurban area, they have some form of medical treatment before hospitalization. Age group most affected is 0-5 age group who are also the vistims of malnutrition. Malnourished cases are associated with longer duration of dysentry before admission. Patients with frequent stool of more than 9 times per 24 hour have more than 60 pus cells per high power field. Common presentations were presence of fever in 71%, abdominal colic in 70% and tenesmus in 84% of cases. Rotavirus was the commonest pathogen in the cool dry month but was absent in the hot wet month. Shigellae, salmonellae and campylobacter were isolated in both seasons, but were not significantly commoner in patients than in controls. The highest incidence of intrabdominal abscess was found in the 20-30 year-age-group and 40-50 year-age-group. Accuracy of ultrasound diagnosis in pelvic abscess was 100 percent and that of clinical diagnosis was also only 83. In both pelvic and liver abscesses, ultrasound could provide valuable information regarding to the nature of abscesses thus helping to improve the timing and approach of treatment. The false-positive result of ultrasonography for the appendicular abscess is one example of limitations of ultrasound. Proper and complete clinical findings should be provided to the radiologist whenever a suspected case of intraabdominal abscess is being investigated. Sensitivity of the ultrasound in this study was found to be 100 percent and specificity was 80 percent. The overall accuracy of ultrasound diagnosis in 74 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar intrabdominal abscesses in this study was found to be 96. In this study, ultrasound was found to provide information required to dictate the line of treatment. All the isolates are found to be Kanagawa positive and the clinical features comprise two syndromes (i) rice watery diarrhea (ii) dysenteric diarrhoea. Accompanying symptoms like dehydration, abdominal pain, nausea, vomiting and fever are also present. These Burmese isolates are resistant to Sulphonamide and Tetracycline and sensitive to Chloramphenicol, Streptomycin, Gentamycin, Septrin and Ampicillin. The sodium balance in children with and without malnutrition, and the state of the homeostatic mechanisms controlling the sodium balance in children with and without malnutrition in acute diarrhoea were assessed. Malnourished children lost more sodium in stool and urine than those without malnutrition. The gut net sodium balance and the total body sodium balance during acute diarrhoea in children with malnutrition showed that they retained less sodium than children without malnutrition. These findings suggest reduced conservation of sodium by the gastrointestinal tract and the kidneys. The present study demonstrated that malnourished children could not conserve sodium and, therefore, ran a high risk of developing sodium depleted state during acute diarrhoea. Summing up Most of the studies during this period were carry-over, continuation, refinement and completion of studies initiated in the previous decades and some or many of the publications were reviews, amalgamations or different presentations of previous reports at different forums. But a few were significant new ventures which brought gastro-intestinal studies to the threshold of exciting and entirely new fields of study. The contamination of soil, water and vegetables with intestinal parasites was studied. Screening for anti-helminthic and anti-gastric activity was done on some reputed traditional medicinal plants - including taw-kyet-thun and pineapple.

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Music therapy has been shown to decrease pain and anxiety buy loratadine from india, and improve quality of life purchase generic loratadine online, mood buy loratadine in india, and speech. Photo by Kulas Foundation & Taxel Image Group, 2008 Community Partnership for Arts and Culture 11 Creative Minds in Medicine lifing the spirit You expect to see and feel certain things when you go to the hospital: white coats; cold stethoscopes; hard, sterile, gleaming surfaces; worry. You don t generally expect to fnd musicians playing there or spaces flled with colorful art. The surprise you get when you walk into the arts-flled Cleveland Clinic may be part of your treatment. The Arts and Medicine Institute was formed in 2008 to build on Cleveland Clinic s solid tradition of mixing art with health care, she says. Since its founding in 1921, Cleveland Clinic has been known for displays of fne art on its walls and of artistic talent from its employees. With the Institute in place, arts of all kinds have become an offcial part of Cleveland Clinic s health mission and programming, explains Maria Jukic, executive director of Arts and Medicine. Those goals have allowed the Clinic s range of arts therapies and programs to expand and deepen: Jukic and her colleagues are making more art available on Clinic campuses, fnding more ways of using it to heal, and identifying more people who need its good effects. And art improved their few things take you out of yourself or cheer you up faster than an unexpected delight: mood... Jukic calls it normalizing, a process art can create that helps people feel more in control, less fearful. True, the sick remain the Clinic s central concern and patients are measurably benefting from the presence of art and musicians a 2012 Clinic survey found 91 percent of patients responding reported that visual art improved their mood during hospital stays of two to three days. That program, which focuses on visual art, manages Cleveland Clinic s existing art collection, This is something and adds to that collection by commissioning and acquiring new pieces. Many of the programs and works of art have been subsidized by donations from grateful patients and visitors to Cleveland Clinic. Committees of experts including curators select the pieces to be bought and/or displayed. The quality of the art selected must be high, says Cohen, because it needs to stand the test of time. Those who choose the art aim for eclectic media and subject matter, because Cleveland Clinic has a global reach, and staff and patients from all over the world. It wants to refect those many different viewpoints, which is also far more interesting and engaging to a diverse population across Cleveland and other geographic areas, she adds. Yet the something-for-everyone approach does contain one other qualifcation: Cleveland Clinic art needs to have something positive to say about the human condition and spirit. Art that s collaborative and/ or environmentally conscious, art that calms, comforts, amuses or uplifts these are the kinds of images and objects that contribute to healing. Water, landscapes, sunlight such subjects tend to mellow people s moods and brighten their outlooks. Cohen says that one of Cleveland Clinic s most successful pieces is a video by Jennifer Steinkamp of a tree that went through seasonal changes. Others danced in front of it, and the wall had to be repainted frequently because so many viewers tried to touch and hug it. They can also help decrease the amount of staff turnover by making the workplace less stressful. So there are economic benefts to having an arts program but the value of the Arts and Medicine Institute is much greater than that, Fattorini says. Photo by Cleveland Clinic Photography Below: Docents lead tours of the Cleveland Clinic art collection several times per week. Patients suffering from memory loss and their caregivers enjoy a special tour program monthly. Photo by Jim Lang Community Partnership for Arts and Culture 14 Creative Minds in Medicine the intersection of arts and health What is the Arts and Health Intersection? From writing poetry or playing music with friends to taking photos or experiencing theater, arts and culture serve as outlets for individual learning, expression and creativity. Participation in arts and culture has been shown to yield positive cognitive, social and behavioral outcomes for human development and for overall quality of life throughout the human lifespan. Because of its ability to span both personal and public spheres in varying degrees, arts and culture participation can yield far-reaching results. At another level, the paintings can be developed into public murals that call attention to areas or issues in need of improvement. Even further, the paintings can become an exhibition that rallies the broader community, encouraging it to take actions that address neighborhood challenges. In this way, a multifaceted view of impact is critical to develop a full understanding of the ways in which arts and culture infuence the human condition on a personal and global scale. In a similar way, an inquiry into the nature of the arts and culture / health and human services intersection (referred to hereafter as the arts and health intersection, for simplicity) requires4 a multifaceted approach. In this general sense, the terms arts and health can be ambiguous because their defnitions are dependent on the manner through which they intersect. Defnitions are ultimately determined by who is participating in the arts and health intersection, where the intersection takes place and what the intersection s goals are. Clinical outcomes in physical and mental health, improved health and human services delivery and personal enjoyment of arts and culture all exist on the continuum of this creative intersection. Artistic practice commonly challenges convention, organically develops new methods and accepts subjective outcomes, while protocols for health practice and clinical outcome measurement demand greater rigidity. In these ways, arts and culture have the10 ability to span multiple disciplines and be applied through a wide range of methods. This ability makes arts and culture interventions useful in responding to the unique needs and concerns of individuals that arise in multiple healthcare situations. Arts and Health in Cleveland Cleveland is fortunate to be home to world-class sets of healthcare and cultural institutions. Meanwhile, Cleveland s arts and culture institutions have multiplied in number and discipline, expanded in size and reputation, and become renowned attractions for both local and international audiences. The Framework of this White Paper While Cleveland is known for the strength of its arts and culture and health and human services sectors, the intersections of those sectors are still being explored and developed. This white paper examines the concept of such intersections with a brief historical perspective on the development of the feld. The organization of subsequent chapters is based on a number of examples of real-life programs and practices illustrating the many ways in which arts and culture contribute to healthcare practice and human services delivery:11 Arts integration in healthcare environments. Community Partnership for Arts and Culture 16 Creative Minds in Medicine Arts and health integration with community development, public health and human services. In the following chapters, these categories will be defned more fully and will highlight key examples of arts and health collaborations that are happening in Cleveland. The fnal sections of this paper will introduce best practices and policy recommendations to further strengthen Cleveland s arts and health intersections in the future.

An acute inammatory arthritis resulting from urate An acuteepisodeofgoutmaybeprecipitatedbyasudden crystal deposition secondary to hyperuricaemia buy loratadine in india. Pathophysiology r Injointsanacutesynovitismayoccurwhenuratecrys- Age tals have been phagocytosed cheap loratadine 10 mg on-line. Sex r If chronic order loratadine visa, the crystals accumulate in the synovium 10M:1F and sites such as the ear cartilage forming lumps termed tophi. Theresultof urate damage is either tubulointerstitial disease (urate Aetiology nephropathy) or acute tubular necrosis. High levels of uric acid cause gout but not all individuals with hyperuricaemia will develop gout. Hyperuricaemia Clinical features is associated with increasing age, male sex and obesity, In 70 90% the initial attack of gout affects the big toe. These features ratesofuricacid production or decreased uric acid make it difcult to distinguish from a septic arthritis. Other joints affected include ankles, knees, ngers, el- r Increased uric acid production may be idiopathic or bowsandwrists. Chronicgoutisunusualbutmaycausea secondary to excessive intake or high turnover as seen chronic polyarthritis with destructive joint damage with in malignancy (especially with chemotherapy). Metabolic bone disorders Management Acute gout is managed with high dose nonsteroidal anti- inammatory drugs. Hyperuricaemia is treated only if Osteoporosis associated with recurrent gout attacks. Excess purines are excreted as xan- thine rather than uric acid, and the therapy is lifelong. Overall 30% of individuals will have a pathological frac- ture due to osteoporosis. It is thought that osteoporosis rophosphate production leads to local crystal formation. The risk of fractures increases with bone shed from the cartilage in which they have formed. Factors that can affect the re- modelling balance are as follows: r Sex: Females have a lower bone mass and a high rate of Clinical features bone loss in the decade following the menopause. This Chondrocalcinosis may be detected on X-ray in cartilage is largely oestrogen-dependent, early menopause and without joint disease. Acute joint inammation resem- ovariectomy without hormone replacement therapy bles gout most commonly affecting the knee and other predisposes. Examination of the joint uid will demonstrate posi- r Genetic factors implicated include the vitamin D re- tively birefringent crystals. Aetiology Pathophysiology Osteomalacia is usually due to a lack of vitamin D or its Although there is low bone mass it is normally min- activemetabolites,butitmaybecausedbyseverecalcium eralised. The structural integrity of the bone is During bone remodelling vitamin D deciency results in reduced, causing skeletal fragility. Clinical features Osteoporosis is not itself painful; however, the fractures that result are. Typical sites include the vertebrae, distal Clinical features radius(Colles fracture)andtheneckofthefemur. Other Onset is insidious with bone pain, backache and weak- symptomsofvertebralinvolvementarelossofheightand ness that may be present for years before the diagnosis is increasing kyphosis. Vertebral compression and pathological fractures may occur; a biochemical diagnosis may be made prior Investigations to onset of clinical disease. Investigations r X-rayinvestigationshowsfractures,abonescancanbe r X-ray investigation shows generalised bone rarefac- used to demonstrate recent fractures. Looser s zones bone density is difcult to assess as the appearance is may be seen in which there is a band of severe rarefac- dependent on the X-ray penetration. Maleswith A disorder of bone remodelling with accelerated rate of gonadal failure benet from androgens. Viral infections may also be involved in the aetiology, including canine dis- Genetic musculoskeletal temper virus and measles. Paget s disease may be due to disorders a latent infection in a genetically susceptible individual. Achondroplasia Pathophysiology Osteoclastic overactivity causes excessive bone resorp- Denition tion. There follows osteoblast activation in an attempt Achondroplasiaisaformofosteochondroplasiainwhich to repairthelesion. Clinical features Incidence Most patients are asymptomatic and the disease is dis- Commonest form of true dwarsm. On examina- Age tion the bone may be bent and thickened, most obvious Congenital, usually obvious by age 1. With widespread bone involvement there may be a bowing of the legs and con- siderable kyphosis. Disproportionate shortening of the long bones of the limbs with a normal trunk length. The head is large Investigations with a prominent forehead and a depressed bridge of Characteristically there is a very high serum alkaline the nose causing a saddle shaped nose. There is a large lumbar lordosis, which causes phate reecting the high bone turnover. A tri- ing periods of immobilisation in active disease the serum dent deformity of the hands may be present. Patients may develop neurological problems due to r Correction of deformities if necessary by surgical in- stenosis of the spinal canal; this may require surgical in- tervention. Denition Aheterogenous disorder with brittle bones and involve- ment of other collagen containing connective tissue. Denition Metastatic cancer is much more common than primary Aetiology bone cancer. Bluescleraresultfrom Two thirds of bone secondaries arise from adenocarci- a thinning of the sclera, which allows the colour of the nomas of the breast or prostate. Metastases usually appear in the Clinical features marrow cavity, damaging bone both directly through Features and classication are given in Table 8. Thetriadofotosclerosis, Patients may present with bone pain or a pathological blue sclera and brittle bones is termed van der Hoeve s fracture. Investigations TheX-raytypicallydemonstratesadestructivelyticbone Primary bone tumours lesion, although some metastases appear sclerotic (e. Vasculitis Management Symptomatic treatments include analgesia, local ra- Vasculitis is an inammatory inltration of the wall of diotherapy and chemotherapy, internal xation of any blood vessels with associated tissue damage. The underlying Investigations mechanisms of the disorders are not fully understood. There may ordersuchassystemiclupuserythematosus,rheumatoid be anaemia of chronic disease.

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