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By L. Raid. Loyola University, New Orleans.

Those who conform buy rumalaya liniment 60 ml lowest price, whether out of greed discount 60 ml rumalaya liniment, cowardice purchase cheap rumalaya liniment, stupidity or genuine enthusiasm. Fascism and communism are histori- cal forms of totalitarianism which are unlikely to re-emerge in the same form in Western democracies, and even less so under the same name. The brave new world of the year 2000 is being heralded in the name of medical science, genetics, and the promise of longevity. The criminalisation of motherhood was dis- cussed by Ernest Drucker, professor of epidemiology and social medicine at Montefiore Medical Center in the Bronx, where about a quarter of all women who give birth use drugs, 46 such as cocaine. About half of the newborn babies who test positive for drugs are removed from their mothers and placed in foster care. Drucker illustrated this practice in a case of a poor Puerto-Rican woman, whose baby was taken away from her after birth. She had a complication of pregnancy known as placenta praevia and the baby died shortly after birth. Annas asked: Does it make any sense to decree that the pregnant woman must, in effect, live for her foetus? That she commits a crime if she does not eat only healthy foods; smokes cigarettes or drinks alcohol; takes drugs (legal or illegal); has intercourse with her husband? Favouring the foetus radically devalues the pregnant woman, and treats 158 Coercive medicine her like an inert incubator, or as a culture medium for the foetus. Women have always been unequal citizens, at least in medical eyes, but this has been obscured by the rhetoric of equality. Women have been barred from employment that was con- sidered harmful to a foetus, even if they were not pregnant. In 1978, American Cyanamid banned all women of childbear- ing age (defined as 16 to 50) from their plant in West Virginia, unless they could prove that they had been sterilised. Free sterilisation was offered and five women accepted it rather 48 than being dismissed. A Nevada woman who drank some beer the day 49 before she went into labour lost custody of her child. The New England Journal of Medicine reported 21 such cases in women who were, as a rule, single, poor, and coloured; Acceptance of forced caesarean sections, hospital deten- tions, and intra-uterine transfusions may trigger demands for court-ordered pre-natal screening, foetal surgery, and restrictions on the diet, work, athletic activity and sexual 50 activity of pregnant women. The woman did not consent, so she was brought to court, where her doctor claimed that there was a 99 per cent probability that the child would die and a 50 per cent probability that the mother would die, if a caesarian section was not performed. She won an appeal to the Georgia Supreme Court and, shortly after- wards, delivered a healthy baby without surgical inter- 52 vention. While some women may be forced to keep their pregnancy against their will others may be prevented from becoming pregnant. It usually takes some 15-20 years before American fashions in public health are adopted in Britain. Yet a High Court in London, in October 1992, ordered an emergency caesarean section on a 30-year-old woman, who refused the operation on religious grounds. In 1992, in Erlangen, Germany, an 18-year-old woman was killed in a car accident and since she was carrying a four-month-old 160 Coercive medicine foetus it was decided to keep the brain-dead woman on a life-support machine until the baby could be delivered. Police powers may even extend to forcing women to undergo a gynaecological examination if there is a suspicion that they have had an illegal abortion abroad. According to a study carried out in 1991 by the Max Planck Institute for Foreign and International Law in Freiburg, there were about ten such cases a year, especially in women returning to Ger- 58 many from the Netherlands. As early as 1963, Erwin Goffman noted that: Only one completely unblushing male in America is a young, married, white, urban, northern, heterosexual Protestant father of college education, fully employed, of good complexion, weight and height and a recent record 60 of sports. Medical screening of healthy humans is the latest addition to collecting information on private citizens. It is the apparent benevolence of the purposes of health screening - to prevent disease and to prolong life - which makes it particularly dangerous, as its more sinister aspects go unnoticed. Epidemiologists, physicians, and other policy makers often treat an estimate of the likelihood of something happening 62 to an individual as an important fact about him. This new statistical or actuarial concept of risk only became part of health promotion rhetoric in the 1970s. This develop- 162 Coercive medicine ment is in line with the neopuritanical tendency towards nor- malisation. Yet, clearly, it is not homosexuality which causes the disease, and even if all homosexuals were exterminated, it would not eradicate the disease. In general, the study of risk factors and their detection in individuals does not bring us nearer to an understanding of causal mechanisms. More often than not, risk factors obscure rather than illuminate the path towards a proper understand- ing of cause. Hagen Kuhn pointed out that prevention based on risk-factor epidemiology is governed by the kind of logic by which room temperature may be lowered by placing the 65 room thermometer into a bucket of ice. The information which accrues from risk-factor screening is hardly ever of any benefit to the person screened, but is of advantage to screeners. In communist countries, regular health checks were often made compulsory, and this is now spreading to Western democracies. Mis- use of screening at the workplace and by insurance companies is discussed below. Allegrante and Sloan provided a psychological explanation for modern victim blaming: We tend to perceive the world as a just place in which people get what they deserve and deserve what they get. This applies not only to those people who are the benefici- aries of positive events, but also to those who are vic- timized by misfortune. Refusal to treat stigmatised persons, however, is now widely supported by the medical profession. In the Erewhonian world illnesses were considered at the same time criminal and immoral. There was a gradation of guilt and of punishment, depending on the seriousness of the disease. While becoming blind or deaf at the age of 65 was dealt with by summary fine, serious disease in a younger person earned a stiff prison sentence. On the other hand, arsonists or cheque forgers were sent to hospital and treated at public expense. It is not uncommon to see paedophiles labelled as diseased and getting more medical attention than their victims. A perusal of medieval penitentiaries would help to disabuse anyone of such a naive notion. As the rules of the power game strongly favour authority against individuals, constant vigilance against renewed threats to freedom (often deceptively described as the enhancement of freedom) is required.

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With mouth-to-mouth ventilations rumalaya liniment 60 ml for sale, the patient receives a concentration of oxygen at approximately 16 percent compared to the oxygen concentration of ambient air at approximately 20 percent purchase line rumalaya liniment. If you are otherwise unable to make a complete seal over a patient’s mouth discount rumalaya liniment 60 ml line, you may need to use mouth-to-nose ventilations: Ÿ With the head tilted back, close the mouth by pushing on the chin. This barrier can help to protect you from contact with a patient’s blood, vomitus and saliva, and from breathing the air that the patient exhales. With your other hand (the hand closest to the patient’s chest), place your thumb along the base of the mask while placing your bent index finger under the patient’s chin, lifting the face into the mask. When using a pocket mask, make sure to use one that matches the size of the patient; for example, use an adult pocket mask for an adult patient, but an infant pocket mask for an infant. Also, ensure that you position and seal the mask properly before blowing into the mask. Also, pay close attention to any increasing difficulty when providing bag-valve-mask ventilation. This difficulty may indicate an increase in intrathoracic pressure, inadequate airway opening or other complications. One rescuer gives 1 ventilation every 6 to 8 seconds, which is about 8 to 10 ventilations per minute. At the same time, the second rescuer continues giving compressions at a rate of 100 to 120 compressions per minute. There is no pause between compressions or ventilations and rescuers do not use the 30 compressions to 2 ventilations ratio. This process is a continuous cycle of compressions and ventilations with no interruption. As in any resuscitation situation, it is essential not to hyperventilate the patient. That is because, during cardiac arrest, the body’s metabolic demand for oxygen is decreased. With each ventilation, intrathoracic pressure increases which causes a decrease in atrial/ ventricular filling and a reduction in coronary perfusion pressures. Hyperventilation further increases the intrathoracic pressure, which in turn further decreases atrial/ventricular filling and reduces coronary perfusion pressures. It is common during resuscitation to accidently hyperventilate a patient due to the emotional response of caring for a patient in cardiac arrest. You should be constantly aware of the ventilations being provided to the patient and supply any corrective feedback as needed. Recovery Positions While not generally used in a healthcare setting, it is important to understand how and when to use a recovery position, especially when you are alone with a patient. In most cases while you are with the patient, you would leave an unconscious patient who is breathing and has no head, neck or spinal injury in a supine (face-up) position and maintain the airway. If the patient is an infant, follow these steps: ŸŸ Carefully position the infant face-down along the forearm. The pads need to be adhered to the skin for the shock to be delivered to the heart. Rescuers may perform compressions from the time the shock advised prompt is noted through the time that the prompt to clear occurs, just prior to depressing the shock button. Be sure to follow the manufacturer’s recommendations and your local protocols and practices. However, take steps to make sure that the patient is as dry as possible, is sheltered from the rain, is not lying in a pool or puddle of water and his or her chest is completely dry before attaching the pads. If this is the case, act swiftly and remove the patch with a gloved hand and wipe away any of the remaining medication from the skin. Rescuers call for a position change by using an agreed-upon term at the end of the last compression cycle. The rescuer providing compressions should count out loud and raise the volume of his or her voice as he or she nears the end of each cycle (… 21 … 22 … 23 … 24 … 25 … 26 … 27 … 28 … 29 … 30). The rescuer at the chest will move to give ventilations while the rescuer at the head will move to the chest to provide compressions. Coordinated, efficient, effective teamwork is essential to minimize the time spent not in contact with the chest to improve patient outcomes. All of these activities could affect your ability to maintain contact with the patient’s chest. One important aspect is minimizing interruptions in chest compressions, which helps to maximize the blood flow generated by the compressions. This coordinated team approach also includes integrating and assimilating additional personnel, such as paramedics or a code team, who arrive on scene. They are supervised by a leader, who keeps the crew on task and gets the race car back on the track. The quality, efficiency and swiftness of the crew’s actions can ultimately affect the outcome of how the race car performs. How you function within a team setting, including how additional personnel assimilate into the team, may vary depending on your local protocols or practice. Integration of More Advanced Personnel During resuscitation, numerous people may be involved in providing care to the patient. Rescuers must work together as a team in a coordinated effort to achieve the best outcomes for the patient. Characteristics of effective teamwork include well-defined roles and responsibilities; clear, closed-loop communication; and respectful treatment of others. Coordination becomes even more important when more advanced personnel such as an advanced life support team or code team arrives on the scene. This coordination of all involved is necessary to: ŸŸ Ensure that all individuals involved work as a team to help promote the best outcome for the patient. Basic Life Support for Healthcare Providers Handbook 23 Ultimately, it is the team leader who is responsible for this coordination. When more advanced personnel arrive on scene, it is the team leader who communicates with advanced personnel, providing them with a report of the patient’s status and events.

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Quarantine guidelines vary depending on the case and factors involved (disease buy 60 ml rumalaya liniment visa, terrain purchase discount rumalaya liniment online, local human and animal populations) but will generally cover at least a 3-5 km radius from the initial case order rumalaya liniment. Movement restrictions are often imposed over a wider area around the quarantined or infected site as part of a zoning strategy which seeks to identify disease infected, disease-free and buffer zone areas [►Section 3. The coverage of the outbreak area and surrounding areas of risk can be determined from surveillance activities and relies on an understanding of the epidemiology of the disease and host ecology [►Section 3. Animal movement within identified zones is not permitted unless appropriate permits have been issued by the local authorities. Trade in certain animals and their products may be permitted under particular circumstances from disease-free zones but only where this has been authorised. Controlled area restrictions may apply whereby the movement of animals outside the protection and surveillance zones is controlled. Imposed movement restrictions and other disease control activities should be communicated promptly and clearly to relevant stakeholders and local communities by local authorities [►Section 3. An integrated disease management strategy, which includes a range of disease control activities such as movement restrictions, zoning, surveillance and vaccination, is often most effective. A disease management strategy for the site should incorporate how best to respond to and cope with movement restrictions. Consideration should be given to voluntary implementation at times of increased risk (e. It should be noted that long term restrictions will affect commercial enterprises and so consideration should be given to incorporation of a business continuity plan into the site contingency plan. Manual of the preparation of national animal disease emergency preparedness plans. Chapter 4, Field manual of wildlife diseases: general field procedures and diseases of birds. This has been achieved for smallpox in 1979, and, more recently, rinderpest in 2011 [►Case study 2-1. Successful eradication programmes produce sustainable improvements in health and many other benefits but depend on significant levels of global co-operation in the sustained and co-ordinated control of infection, usually requiring a combination of approaches. An eradication programme will not succeed in the absence of a sound scientific basis, availability of sufficient resources and public and political will. International coordination and collaboration with regional and national governmental, and non-governmental organisations is essential for the control and eradication of transboundary animal diseases. Disease elimination Elimination of a disease usually refers to the reduction to zero of incidence in a defined geographical area as a result of deliberate efforts. Examples include the successful elimination of polio in the Americas and of neonatal tetanus in 19 countries between 1999 and 2010. Importantly, unless the disease can be globally eradicated, continued disease control intervention measures are needed to prevent re-emergence. Disease elimination in wetlands poses a number of problems particularly in relation to wildlife diseases and water-borne infectious agents. The following measures can aid disease elimination and their merits should be considered within any disease control strategy: Identification of infected zones through intensive disease surveillance [►Section 3. Possible slaughter of infected or susceptible animals using a range of methods [►Stamping out and lethal intervention]. Ensuring that the infected area is free of susceptible animals for an appropriate period of time. The most appropriate use of this approach at a wetland site would be for the rapid elimination of a disease in livestock. Lethal methods include dispatch by firearm or captive-bolt, the use of gaseous, biological or injectable agents. Stamping out may often be a cost-effective approach to disease control in livestock in an emergency situation, as in appropriate circumstances (e. As with all disease strategies, the scientific feasibility, and health, ethical, social and economic costs and benefits of stamping out and lethal intervention should be carefully evaluated before it is selected as a disease control strategy. Lethal intervention has been used for disease control in wildlife, but in wetland sites this may not be consistent with conservation objectives. Hence, the potential costs and benefits of lethal interventions need to be considered carefully. This requires some knowledge of the likely behavioural and demographic responses of host populations to lethal control as these can result in complex outcomes in terms of disease control. However, implementation at the level of individual hosts requires the availability of adequate diagnostic tools, and at the population level it is important to be able to accurately identify the target population. Lethal interventions of invasive alien species or pests is likely to be consistent with conservation objectives but, nevertheless, a sound understanding of the response of the target population is required prior to intervention to help predict impacts. Control, elimination, eradication and re-emergence of infectious diseases: getting the message right. These programmes form some of the most fundamental aspects of managing diseases in wetlands and should be included in all wetland disease management strategies. Successful communication relies upon establishing a regular dialogue between wetland stakeholders and disease control authorities. A ‘culture’ of disease management can only be developed if: a broad range of wetland stakeholders (e. Such programmes should be integrated into all wetland disease management strategies. Programmes should aim to inform wetland stakeholders of the basic principles of healthy habitat management, thus reducing the risk of a disease outbreak. Communication strategies should aim to make stakeholders aware of the nature and potential consequence of animal disease and of the benefits gained from prevention and control measures. They should ultimately encourage people to take the recommended courses of action in preventing and controlling a disease outbreak. Awareness raising campaigns should emphasise the importance of early warning systems and of notifying and seeking help from the nearest government animal and/or human health official as soon as an unusual disease outbreak is suspected. Selection of the appropriate message, the messenger and the method of delivery is critical for successful communication. A strategy, written in ‘peacetime’ for dealing with the media can increase likelihood of successful outcomes from this relationship maximising potential benefits and minimising potential negative impacts. Simulation exercises and testing of contingency plans are a valuable method for training.

Although the plasma compartment is most easily sampled 60 ml rumalaya liniment with amex, the concen- tration of most amino acids is higher in tissue intracellular pools order rumalaya liniment without a prescription. Typically discount rumalaya liniment 60 ml on line, large neutral amino acids, such as leucine and phenylalanine, are essen- tially in equilibrium with the plasma. Others, notably glutamine, glutamic acid, and glycine, are 10- to 50-fold more concentrated in the intracellular pool. Dietary variations or pathological conditions can result in substantial changes in the concentrations of the individual free amino acids in both the plasma and tissue pools (Furst, 1989; Waterlow et al. Pathways of Amino Acid Metabolism The exchange between body protein and the free amino acid pool is illustrated by the highly simplified scheme shown in Figure 10-2. Similarly, there is a second pool, consisting of the free amino acids dis- solved in body fluids. The arrows into and out of the protein pool show the continual degradation and resynthesis of these macromolecules (i. The other major pathways that involve the free amino acid pool are the supply of amino acids by the gut from the absorbed amino acids derived from dietary proteins, the de novo synthesis in cells (includ- ing those of the gut, which are a source of dispensable amino acids), and the loss of amino acids by oxidation, excretion, or conversion to other metabolites. Amino Acid Utilization for Growth Dietary protein is not only needed for maintaining protein turnover and the synthesis of physiologically important products of amino acid metabolism but is, of course, laid down as new tissue. Studies in animals show that the composition of amino acids needed for growth is very simi- lar to the composition of body protein (Dewey et al. It is important to note, however, that the amino acid composition of human milk is not the same as that of body protein (Dewey et al. Maintenance Protein Needs Even when mammals consume no protein, nitrogen continues to be lost. Provided that the energy intake is adequate, these “basal” losses are closely related to body weight and basal metabolic rate (Castaneda et al. In man, normal growth is very slow and the dietary requirement to support growth is small in relation to maintenance needs except at very young ages. It follows that maintenance needs are of particular impor- tance to humans and account for a very large majority of lifetime needs for dietary protein. It has been known for decades (Said and Hegsted, 1970) that the body’s capacity to conserve individual amino acids at low intakes varies, so the pattern of amino acids needed in the diet to match their individual catabolic rates does not correspond precisely with the composition of body protein. This implies that there is very effective recycling of indispensable amino acids released continuously from protein degradation back into protein synthesis. Under conditions where the diet is devoid of protein, the efficiency of amino acid recycling is over 90 percent for both indis- pensable and dispensable amino acids (Neale and Waterlow, 1974). While highly efficient, some amino acids are recycled at different rates than others. Physiology of Absorption, Metabolism, and Excretion Protein Digestion and Absorption After ingestion, proteins are denatured by the acid in the stomach, where they are also cleaved into smaller peptides by the enzyme pepsin, which is activated by the increase in stomach acidity that occurs on feed- ing. The proteins and peptides then pass into the small intestine, where the peptide bonds are hydrolyzed by a variety of enzymes. These bond- specific enzymes originate in the pancreas and include trypsin, chymotrypsins, elastase, and carboxypeptidases. The resultant mixture of free amino acids and small peptides is then transported into the mucosal cells by a number of carrier systems for specific amino acids and for di- and tri-peptides, each specific for a limited range of peptide substrates. After intracellular hydrolysis of the absorbed peptides, the free amino acids are then secreted into the portal blood by other specific carrier systems in the mucosal cell or are further metabolized within the cell itself. Absorbed amino acids pass into the liver, where a portion of the amino acids are taken up and used; the remainder pass through into the systemic circulation and are utilized by the peripheral tissues. Thus, a significant portion (at least 50 percent) of fecal nitrogen losses represents the fixation by the colonic and cecal bacteria of nitrogenous substances (urea, ammonia, and protein secretions) that have been secreted into the intestinal lumen. Some authors have argued that the host-colon nitrogen cycle, by which nitrogenous compounds that diffuse into the gut are converted to ammonia by the microflora and are reabsorbed, is a regulated function and serves as a mechanism of nitrogen conservation (Jackson, 1989). The theoretical basis of this proposition has been partly confirmed by the recent demon- stration of the availability to the host of indispensable amino acids synthe- sized by intestinal microbes (Metges et al. However, not all investigators have obtained results indicative of regulated nitrogen cycling (Raguso et al. Although it seems clear that the efficiency of dietary protein digestion (in the sense of removal of amino acids from the small intestinal lumen) is high, there is now good evidence to show that nutritionally significant quantities of indispensable amino acids are metabolized by the tissues of the splanchnic bed, including the mucosal cells of the intestine (Fuller and Reeds, 1998). Thus, less than 100 percent of the amino acids removed from the intestinal lumen appear in the peripheral circulation, and the quantities that are metabolized by the splanchnic bed vary among the amino acids, with intestinal threonine metabolism being particularly high (Stoll et al. Currently, there is a lack of systematic information about the relationship between dietary amino acid intake and splanchnic metabolism, although there are indications that there is a nonlinear rela- tionship between amino acid intake and appearance in the peripheral blood (van der Schoor et al. Intestinal Protein Losses Protein secretion into the intestine continues even under conditions of protein-free feeding, and fecal nitrogen losses (i. Under this dietary circumstance, the amino acids secreted into the intestine as components of proteolytic enzymes and from sloughed mucosal cells are the only sources of amino acids for the maintenance of the intestinal bacterial biomass. In those studies in which highly digestible protein-containing diets have been given to individuals previously ingesting protein-free diets, fecal nitrogen excre- tion increased by only a small amount. The following points support the view that the intestinal route of protein (amino acid) loss is of quantitative significance to maintenance protein needs. First, continued mucosal cell turnover and enzyme and mucin secretion are necessary for maintaining the integrity of the gastrointestinal tract and its normal digestive physiology. Second, animal studies show that the amino acid composition of the proteins leaving the ileum for bacterial fermenta- tion in the colon is quite different from that of body protein (Taverner et al. In particular, the secretions are relatively rich in dispensable amino acids as well as threonine and cysteine (Dekker et al. These two amino acids are of significance in meeting amino acid needs when intake is close to the requirement (Laidlaw and Kopple, 1987). Other routes of loss of intact amino acids are via the urine and through skin and hair loss. These losses are small by comparison with those described above, but nonetheless may have a significant impact on esti- mates of requirements, especially in disease states (Matthews, 1999). From a nutritional and metabolic point of view, it is important to recognize that protein synthesis is a continuing process that takes place in most cells of the body. In a steady state, when neither net growth nor protein loss is occurring, protein synthesis is balanced by an equal amount of protein degradation. Protein Degradation The mechanism of intracellular protein degradation, by which pro- tein is hydrolyzed to free amino acids, is more complex and is not as well characterized at the mechanistic level as that of synthesis (Kirschner, 1999).

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