This can be achieved by interventions that reduce demand directly discount augmentin 625 mg mastercard infection symptoms, such as drug use prevention cheap augmentin 625mg with amex antibiotics for sinus infection doxycycline, treat- Different criminal justice approaches have a different ment discount 625mg augmentin with mastercard virus x the movie, rehabilitation and aftercare. There are differences across jurisdictions in terms of definitions, Criminal justice interventions can have other indirect and prosecutorial discretion or types and severity of sanctions unforeseen impacts on drug markets. In some regions, countries exer- high-ranking individuals in drug trafficking organizations cise more punitive approaches when dealing with people may trigger restructuring179 and changes in modus oper- apprehended for minor offences, such as possession of andi and crackdowns in one particular area or route may small quantities of drugs for personal consumption, which induce shifts in supply patterns, as traffickers exploit other may result in such offenders being incarcerated. Garzón and John Bailey “Displacement effects of sup- 178 Michael Grossman, “Individual behaviors and substance use: the ply-reduction policies in Latin America: a tipping point in cocaine role of price”, in Substance Use: Individual Behavior, Social Interac- trafficking, 2006-2008”, in The Handbook of Drugs and Society, tions, Markets, and Politics, vol. At the global level, drug-related offences persons, particularly the youngest and most vulnerable. It bery, motor vehicle theft, burglary and homicide, have also often increases social exclusion, worsens health condi- decreased substantially (see figure 22). Alternatives to incarceration that just under a third of the global prison population (30 within the community (in an outpatient or residential per cent over the period 2012-2014, compared with 32 therapeutic setting), such as psychosocially supported per cent over the period 2003-2005) continues to be made up of unsentenced or pretrial prisoners. Female offenders and prisoners, 120 especially those with drug use disorders, face particular figure 23). In many countries, the majority of children who are in detention are either children 6060 Rape (64 countries) affected by drug dependence or children who have com- mitted drug-related offences. Overreliance on the depriva- 4040 Robbery (61 countries) tion of children’s liberty and insufficient application of drug treatment programmes or other alternatives to deten- Motor vehicle theft (64 countries) tion are common challenges,188 despite international obli- gations to use the deprivation of liberty as a measure of Burglary (53 countries)Rape (64 countries)Rape (64 countries) last resort. Drug-related personal consumption offencesDrug-related personal consumption offences (43 countries)Burglary (53 countries) 185 Ralf Jurgens and Glenn Betteridge, “Prisoners who inject drugs: (43 countries) public health and human rights imperatives”, Health and Human Homicide (81 countries) Rights, vol. Source: United Nations Survey of Crime Trends and Operations of 186 “From coercion to cohesion” (see footnote 184). Notes: Trends are calculated as weighted crime rates per 100,000 popu- lation relative to the base year 2003. To produce global estimates, the 188 See the report of the independent expert for the United Nations estimated crime rates for each region were weighted according to theDrug-related personal consumption offences study on violence against children (A/61/299, para. Data on drug(43 countries) thematic report by the Special Representative of the Secretary-Gen- trafficking and drug-related personal consumption offences refer mostly eral on Violence against Children (Promoting Restorative Justice for to persons arrested or prosecuted for those types of crime. Deprived of their Liberty (General Assembly resolution 45/113, 191 Based on data from 74 countries, classifying convictions with multi- annex). This is in line Financial crimes or corruption with the international drug control conventions196 and Drug-related offences with the requirements of an effective penal policy that is Other offences/not known in compliance with human rights standards. The provision of evi- ficking” character of a drug-related offence; they can dence-based treatment and care services to drug-using include the drug type and amount, associated thresholds offenders, as an alternative to incarceration, has been (or none at all), drug purity, position in a gang and whether shown to substantially increase recovery and reduce recidi- the person in question uses drugs. This variation thus makes the comparison of data across countries challeng- 192 Each of the above-mentioned estimates has been calculated on the ing. Global aggregates show that the number of offences basis of the corresponding available data set and presented on the related to personal consumption exceeds the number of assumption that the data set is representative of the global popu- trafficking offences, reflecting the fact that the number of lation. However, the exact coverage, and hence the level of uncer- tainty, differs according to the specific indicator. Moreover, the stipulated periods of 195 See article 3, paragraph 4, of the United Nations Convention imprisonment tend to be longer for trafficking offences. More than three quarters 196 See article 36, paragraph 1 (a), of the 1961 Convention as amended of all persons held in prison for drug-related offences in by the 1972 Protocol, article 22, paragraph 1 (a), of the 1971 Con- vention and article 4 (a) of the 1988 Convention. This highest ranks of power, such as police chiefs, national poli- improves outcomes both for the person with the drug use ticians and high-level law enforcement officials. The prac- disorder and the community when compared with the tice of corrupting officials to facilitate drug trafficking has effects of criminal justice sanctions alone. Alternatives to imprisonment have sometimes been put in Corruption can also vary depending on the strength of place as a response to developments in drug use. For exam- the rule of law and the effectiveness of state institutions; ple, the spread of the use of “crack” in the United States characteristics of the political systems such as the strength in the 1980s was a major factor in prompting the intro- of political parties, the efficacy of the criminal justice duction of “drug courts”. Similarly, the challenging nature system, including its investigative and prosecutorial func- of the drug problem in Portugal in the 1990s set the scene tions, the existence of functioning oversight mechanisms for a turning point in Portuguese drug control policy, as and sanctions for corruption can reduce the extent of drug- well as the institutional setup for its implementation. The organization of criminal groups can also affect the specific interaction between state offi- Corruption, organized crime and illicit cials and criminal groups. In Italy, for example, studies financial flows have found that organized criminal groups with complex internal structures, such as Cosa Nostra and ‘Ndrangheta, Corruption whose activities include, but are not limited to, the illicit Target 16. In other parts of the country, organized criminal groups such as the Camorra and the Apulian groups, which are less hierarchical and strict in Corruption and related forms of crime such as extortion their recruitment practices, have more diffuse, though still engender costs in terms of discouragement or impediment strong, political connections. For example, according to a report by the General Accounting Office in the United States, less than There is a mutually reinforcing relationship between the 1 per cent of employees of the Custom and Border Patrol drug problem and corruption. The illicit drug trade often were arrested on charges of corruption between 2005 and flourishes where state presence and the rule of law are weak 2012; among the 144 employees arrested or indicted for and, thus, where opportunities for corruption exist. At the corruption, pressure from drug trafficking and other trans- same time, the profits and power of drug trafficking organ- national criminal groups was found to be a key factor. Of izations provide them with resources to reinforce corrup- the 144 cases, 103 were found to be “mission-compromis- tion by buying protection from law enforcement agents ing”, including instances involving drug trafficking or the — particularly when the agents’ levels of remuneration smuggling of migrants. There were 32,290 allegations of are low — and from politicians and the business sector; corruption or misconduct during the same period,203 this means that corruption can be the Achilles heel in the which shows that even though corruption may not response to drug trafficking. Low-level or “petty” corruption often starts with street police or local Drug trafficking organizations conduct their business politicians, who may be vulnerable to crime because of a using both corruption and violence. Criminals and drug lack of social legitimacy or because they come from the traffickers use those two strategies simultaneously, and very same communities as members of criminal groups. In many cases, such illicit proceeds protection that criminals might be unwilling to destabilize can inject large cash inflows into a country’s economy and through violence. Predictable cor- countries, some of which have been significantly affected rupt networks — those that guarantee protection from by cocaine trafficking. In Guinea-Bissau, for example, law enforcement — can deter criminals from deploying foreign exchange reserves rose from $33 million in 2003 large-scale violence. Such networks may be more likely to to $174 million in 2008; and in the Gambia, the value of emerge where government power is centralized and the the dalasi increased very rapidly with no clear change in capital inflows. This, in turn, may deter the use of violence they may undermine the integrity of a country’s financial because criminals may prefer to avoid violence, as that system, including its international financial sectors. In the could force the government authorities to target them case of opiates originating in Afghanistan, for example, a more strongly. The transfer of funds between consumer markets and Drugs and illicit financial flows intermediate countries varies significantly, with drug traf- fickers using the full range of money transfer techniques, Target 16. How- arms flows, strengthen the recovery and return of ever, funds moving between intermediate countries and stolen assets and combat all forms of organized Afghanistan seem to make particular use of cash couriers crime and money or value transfer services. Profits from the illicit drug trade can constitute consider- Part of the proceeds from the illicit drug trade generated able financial incentives for organized criminal groups. The money originated from the ranging from the use of small, decentralized techniques, Sinaloa cartel in Mexico, the Norte del Valle cartel in Colombia and other smaller drug trafficking organiza- tions. Durán-Martínez, “Drugs, Violence, and 209 West Africa Commission on Drugs, Not Just in Transit: Drugs, the State-sponsored protection rackets in Mexico and Colombia”, State and Society in West Africa (2014). However, over the same Given the extensive interplay that exists between sustain- period, the magnitude of commitments towards the sectors able development and drug control, development assis- specific to drug-related matters, namely “alternative devel- tance and capacity-building must also be channelled into opment” (agricultural and non-agricultural)214 and “nar- measures to counter the world drug problem.
In this fully residential posting 625 mg augmentin with mastercard virus 0xffd12566exe, the distribution of posting is as under: (a) Six weeks posting at Ballabgarh Hospital ( a 60 bedded discount augmentin 625mg overnight delivery bacteria in yogurt, secondary care level hospital) : This posting aims to train the interns in managing common health problems at secondary level generic 625mg augmentin fast delivery antibiotic resistance youtube. The interns are trained to manage common health problems at the primary level under the ambit of primary health care. The aim of the training is to train the candidates to diagnose and manage common skin diseases. Diagnose and manage common skin diseases, sexually transmitted diseases and leprosy. To diagnose and manage common medical emergencies related to skin diseases, leprosy and sexually transmitted diseases. To familiarize them with the common laboratory diagnostic skills which help in the confirmation of diagnosis. To train them for preventive measures at individual and community levels against communicable skin diseases including sexually transmitted diseases and leprosy. Clinical examination and description of cutaneous findings in a systematic way in dermatology, sexually transmitted diseases and leprosy. To have a broad idea and approach to manage common skin diseases, sexually transmitted diseases and leprosy. To develop skills to do day-to- day common laboratory tests and their interpretation which help in the diagnosis. Ineffective dermatoses: Pyoderma, tuberculosis and leishmaniasis- Etiology, Clinical features, Diagnosis and Treatment. Infective dermatoses: Viral and fungal infections- Etiology, Clinical features, Diagnosis and Treatment. Infestations: Scabies and pediculosis – Etiology, Clinical features, Diagnosis and Treatment. Melanin synthesis: Disorders of pigmentation (Vitiligo, Chloasma / Melasma)- Etiology, Clinical features, Diagnosis and Treatment. Allergic disorders: Atopic dermatitis and contact dermatitis – Etiology, Clinical features, Diagnosis and Treatment. Drug eruptions, urticaria, erythema multiforme, Steven’s johnson syndrome and toxic epidermal necrolysis – Etiology, Clinical features, Diagnosis and Treatment. Vesiculo-bullous diseases: Pemphigus, Pemphigoid, Dermatitis herpetiformis – Etiology, Clinical features, Diagnosis and Treatment. Epidermopoisis, Psoriasis, Lichen planus and Pityriasis rosea – Etiology, Clinical features, Diagnosis and Treatment. Pathogenesis, Classification and clinical features of leprosy, Reactions in leprosy. Gonococcal and Non-gonococcal infections – Etiology, Clinical features, Diagnosis and Treatment. Syndromic approach to the diagnosis and management of sexually transmitted diseases. Hereditary disorders: Ichthyosis, Albimism, Epidermolysis bullosa, Melanocytic naevi, Freckles and other naevi – Etiology, Clinical features, Diagnosis and Treatment. They have the clinical teaching and demonstrations of all the common skin diseases sexually transmitted diseases, leprosy and common skin emergencies during this period. They also have about a week’s orientation clinical posting during their 3rd semester training period to familiarize them with the history taking, clinical examination and cutaneous lesions. Clinical Assessment: The students go through an assessment at the end of their clinical postings. Elicit a detailed history, perform a thorough physical examination including mental status 4. Correlate the clinical symptoms and physical signs to make a provisional anatomical, physiological, etiopathological diagnosis along with the functional disability and suggest relevant investigation. Professionally present and discuss the principles involved in the management of the patient, initiate first line management and outline short-term and long term management. Manage acute medical emergencies like acute myocardial infarction, acute pulmonary oedema, acute anaphylactic and hypovolumic shock, status asthmaticus, tension pneumothorax, status epilepticus, hyperpyrexia, haemoptysis, gastro-intestinal bleeding, diabetic coma, electric shock, drowning, snake bites, common poisoning etc. Didactic lectures: discussion a particular topic at length in an one hour lecture 2. Seminars: conducted by a combined team of clinician, pathologist and microbiologist discussing a particular topic for two hours 3. Clinical training: The clinical training of undergraduate medical students occurs in four phages: a. During medical posting undergraduates will also be asked to attend specialised department like cardiology, neurology. Medical students are supposed to complete the logbook and signed by faculty after every clinical case discussion. Harrison’s Principles of Internal Medicine, McGraw Hill publications (Reference book) 4. Practical & clinical training - Students should be trained about proper history taking, clinical examination. Observe normal deliveries, forceps and ventouse assisted deliveries, cesrean section. Normal & abnormal development, structure and function of female & male urogenital systems and the female breast. Applied anatomy of the genito-urinary system, abdomen, pelvis, pelvic floor, anterior abdominal wall, upper thigh (inguinal ligament, inguinal canal, vulva, rectum and anal canal). Anatomical & physiological changes in female genital tract during pregnancy fistulae. Anatomy of fetus, fetal growth & development, fetal physiology & fetal circulation. Physiological & neuro-endocrinal changes during puberty disorders, adolescence, menstruation, ovulation, fertilization, climacteric & menopause. Biochemical and endocrine changes during pregnancy, including systemic changes in cardiovascular, hematological, renal, hepatic and other systems. Biophysical and biochemical changes in uterus and cervix during pregnancy & labour. Pharmacology of identified drugs used during pregnancy, labour, post partum period with reference to their mechanism of action, absorption, distribution, excretion, metabolism, transfer of the drugs across the placenta, effect of the drugs on the fetus, their excretion through breast milk. Mechanism of action, excretion, metabolism of identified drugs used in Gynaecology, including chemotherapeutic drugs. Pathophysiology of ovaries, fallopian tubes, uterus, cervix, vagina and external genitalia in healthy and diseased conditions. Normal and abnormal pathology of placenta, umbilical cord, amniotic fluid and fetus. Normal and abnormal microbiology of the genital tract – bacterial, viral & parasitic infections responsible for maternal, fetal and gynaecological disorders. Physiology of normal pregnancy, diagnosis of pregnancy, routine antenatal care, management of common symptoms in pregnancy, investigations to be carried out in pregnancy; 2. Anatomy of fetal genital tract, and its variations, supports of uterus, developmental anomalies of uterus. They will be allocated beds in the wards and completed to work up these cases for case discussions with faculty.
Inflammatory disorders The human body has a complex system of natural Free radicals and oxidative stress may play a role in enzymatic and nonenzymatic antioxidant defences which inflammatory diseases augmentin 625 mg with mastercard antibiotic resistance ted ed. Rheumatoid arthritis is one counteract the harmful effects of free radicals and other example generic augmentin 625mg visa bacteria with flagella list. Protection against free radicals can be enhanced been detected in the blood and joints of patients with by ample intakes of dietary antioxidants buy generic augmentin 625 mg on line zombie infection nokia 5228, of which the this disease. Other lines of evidence also suggest the best studied are vitamin E, vitamin C and carotenoids. Efforts should be made to ensure optimum intakes of foods containing these important molecules. There is a need for improvement in the quality of the diet, Oxidants and Antioxidants 23 especially with respect to increased consumption of ß-Carotene: The most abundant of the carotenoids. Unlike including optimisation of food processing, selective vitamin A itself, ß-carotene is a strong antioxidant. There is, however, a growing consensus among Carcinogenesis: The complex, multistep process of scientists that a combination of antioxidants, rather than cancer causation. Carotenoids: A group of red, orange, and yellow pigments found in plant foods and in the tissues of Antioxidants may be of great benefit in improving the organisms that consume plants. Carotenoids have antioxidant activity, and some, but not all, can act as quality of life by preventing or postponing the onset of precursors of vitamin A. In addition, there is a potential for Cataract: A disorder in which the lens of the eye substantial savings in the cost of health care delivery. More research is needed to clarify and extend scientific Epidemiology: The study of the causes and understanding of the health effects of antioxidants. Funding for research in this field is urgently Free radical: Any chemical species capable of independent existence that contains one or more needed. At the same time, efforts should also be made to Glutathione: A small-molecular-weight antioxidant communicate to the general public existing information molecule produced naturally in the human body about the importance of protective nutrients in fruits and and present in some foods. Government agencies, health professionals Glutathione peroxidases: A family of antioxidant and the news media should work together to promote enzymes containing selenium which are important the dissemination of scientifically sound information in the reduction of different hydroperoxides. Lycopene has antioxidant activity but 1993; 90:7915–7922 does not act as a precursor of vitamin A. Oxygen Free Radicals Oxidative stress: A condition in which the and Human Diseases. Antioxidant Nutrients and Disease Placebo: A harmless and pharmacologically inactive Prevention: An Overview. American Journal of Clinical substance, usually disguised, given to compare its Nutrition 1991; 53:189S–193S effect with that of an active material. Reperfusion: The reoxygenation of tissue that has Molecular Aspects of Medicine 1994; 15:293–376 been deprived of adequate oxygen (ischæmia) as a Ernster L, Forsmark-Andrée P. Ubiquinol: A n result of either surgical procedures or physiological Endogenous Antioxidant in Aerobic Organisms. Vital organs can tolerate only a brief Investigator 1993;71:S60–S65 period of oxygen deprivation before cell injury and Frei B (ed). Free Radicals in Biology and damage can be prevented or decreased in the Medicine, 2nd ed. Oxygen Radicals in believed to play an important role in cellular Biological Systems, part B: Oxygen Radicals and defence against oxidative damage. Active Oxygen, Lipid Peroxides and detailed information on this subject can be found in the Antioxidants. European Food Packaging and Migration Research van Havere Directory Ellis Horwood Series in Food Science and Thechnology 1994. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. However, it is not always clear which is the most appropriate treatment for the patient and whether the choice should be affected by age, clinical condition, or other factors. As the disease progresses, combination therapy is usually prescribed but there are gaps in clinical knowledge about when this should be initiated and what combinations of therapies are most effective. The role of the allied health professionals and the benefits of neurosurgical management of Parkinson’s disease, such as deep brain stimulation, have not been covered. The management of some non-motor symptoms is not included in this guideline as in many cases their management is not significantly different from that in people without Parkinson’s disease. A wide range of medical disciplines is involved in routine management reflecting the fact that Parkinson’s disease is much more than simply a disorder of physical movement, and that the neurological involvement frequently causes symptoms across many different functional areas, such as mental health, bowel, bladder and blood pressure. Parkinsonism is a broader, less specific, term than Parkinson’s disease, and is used as an umbrella term to describe the clinical profile without being specific as to the cause. This may be small vessel disease in the subcortical areas and/or brainstem, and/or in association with larger artery occlusion. A description of the classic parkinsonian syndrome described by James Parkinson (see Annex 2). Bradykinesia is slowness of initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions. Dementia is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal ageing. Dyskinesia is involuntary movement with a rotatory, writhing appearance, which can affect the limbs, trunk and face, and occurs as Parkinson’s disease progresses. With the use of levodopa for several years, many patients will develop fluctuating responses to the drug which can be divided into ‘on and off’ motor states. During ‘on’ periods, a person can move about and perform activities of daily living with relative ease, often with less tremor and rigidity. Some individuals can experience involuntary writhing movements as the medication effect reaches its peak; this is referred to as ‘on with dyskinesias’. Walking, eating, bathing and even speaking may be more impaired during an ‘off’ period and there may be non-motor manifestations such as low mood or fatigue. The most common time for a patient to experience an ‘off’ episode is when their medication is losing its effect prior to the time for the next dose. The freezing often occurs at the beginning of walking (start hesitation/gait initiation failure) but can also occur when the patient turns, confronts obstacles or distractions such as narrow doorways, or during normal walking. The individual episodes of freezing are usually brief (lasting seconds) and are not associated with worsening upper limb parkinsonism unlike ‘on-off’ fluctuations, with which they are often confused. It is the number of subjects with a positive test who have disease divided by all subjects who have the disease. It is the number of subjects who have a negative test and do not have the disease divided by the number of subjects who do not have the disease. If a test is positive, the pre-test odds of having the condition can be multiplied by the lR+ to give the post-test odds of having the condition. An lR+ of between 3 and 10 implies a moderately useful test, whereas an lR+ ≥10 implies a positive test can be used to rule in the condition. If a test is negative, the pre-test odds of having the condition can be multiplied by the lR- to give the post-test odds of having the condition.
The standards of practice change quickly and it would be unfair to review the work of the physician in the light of later practice buy discount augmentin 625mg virus encrypted my files. In recent years concerns have been raised about the emergence of a counsel of perfection being advocated by some experts who are called to give evidence on behalf of the plaintif purchase augmentin master card antibiotics vre. The standard is not These experts seem to apply a textbook standard in assessing the work of the defendant one of excellence physician augmentin 375mg sale bacteria urinalysis. There is doubt whether these experts or, for that matter, physicians in general are or perfection, but is able to adhere to these high standards on all occasions. The most common reason for unrealistic expert opinion appears to relate to the failure of many experts to appreciate or understand their role in the legal process. It bears repeating that the function of the expert is to advise the court as to the proper standard of care against which the defendant physician is to be judged. The standard is not one of excellence or perfection, but is rather the level of care and skill that could reasonably be expected of a physician with similar training and in similar circumstances to those of the defendant physician. Treating physicians as experts On occasion, the attending physician may also be requested to act as an expert to provide an opinion beyond the care and management of the patient that relates more to medical-legal issues. It is solely the physician’s own personal choice and professional judgment whether to accept such a retainer. Treating physicians are under a professional obligation to provide copies of a patient’s records and, if requested, a report about the care and management of the patient. While generally factual in nature and addressing clinical observations, diagnosis, and treatment given, the report may also include comments and opinions about the underlying cause of the patient’s medical condition and the clinical prognosis. The expert report Physicians assuming the role of an expert should ensure that legal counsel has provided all the relevant documents for review so the physician is aware of all of the pertinent facts and issues 16 Medical-legal handbook for physicians in Canada on which to base an opinion. These documents should include the legal pleadings, all relevant medical records of the patient’s treatment, transcripts of the evidence from examinations for discovery, and, where appropriate, the reports of other experts. The expert should always pay careful attention to, and follow the directions of, the instructing legal counsel. Experts should raise with the instructing lawyer, at the outset, the issue of payment for reviewing documents and preparing the expert report. This discussion should extend to the time the expert might be required to devote to prepare for an attendance at any trial of the action. Following this discussion, the expert might write to the instructing lawyer setting out the terms and conditions of the retainer and the payment arrangements. Most legal counsel fnd it helpful if experts organize their report using key headings where possible, for example: ▪ Address the report to the lawyer or individual who requested it, never “To Whom It May Concern. Indicate whether the expert has been retained to provide an opinion on the standard of care or approved practice (“You have requested my opinion as to whether the medical treatment rendered to the patient met the level expected for standard care”), on the issue of causation (“You have asked me to comment on the diagnosis of the medical condition and whether earlier treatment would have afected the outcome”), or on the assessment of disability (“This report is prepared following my independent medical examination of the patient”). Although the expert will likely have to provide a complete curriculum vitae to instructing counsel, it is helpful to include a paragraph summarizing the most pertinent details. For example, “I am a (name of specialty) and obtained my Fellowship from the Royal College of Physicians and Surgeons of Canada in (year). I have practised as a (name of specialty) in (name of city) for the last 30 years and was, until recently, chief of surgery at the local hospital and former chairman of the department of surgery at the faculty of medicine. In an increasing number of jurisdictions, experts are being expressly required to include certain information in their legal reports, including an acknowledgement of their duty to provide opinion evidence for the court that is fair, objective, non-partisan, and related only to matters that are within the expert’s area of expertise. This should be a complete list of all the relevant materials received from the instructing lawyer and reviewed in preparing the report. The dates of any medical examinations of the patient should also be included in the list. Reference might also be included to any specifc literature or research data upon which the expert may have relied. A narrative may have been provided by the instructing lawyer, but the expert should prepare a personal medical summary of the chronology as confrmed by the relevant medical records. Any medical examination, diagnostic investigation, or functional assessment of the patient should be reviewed in detail. This will normally involve the analysis and opinion of the expert on the issue in question. In a medical negligence claim, for example, the expert should identify and comment on the failures, if any, in the medical care rendered and whether such defciencies caused any direct harm or injury to the patient. There is also a trend to require The Canadian Medical Protective Association 17 experts to not only state their own opinion, but as well to comment on and distinguish alternative or competing opinions relating to the issues being addressed. Guidelines for giving evidence A physician summoned or subpoenaed to give evidence in legal proceedings, including those in any court or before any board or tribunal, must answer all questions asked when under oath. Only communications between lawyers and their clients are fully privileged and protected from disclosure, even in court. A physician who refuses to answer questions asked under oath may be held in contempt of court and fned or even sent to jail. The courts do have some discretion, however, particularly in the areas of mental health and family relations, to excuse a physician from answering questions where the potential harm caused by the disclosure of the confdential medical information may be greater than any beneft to be gained by such disclosure. Often physicians will be asked to give evidence as the attending physician who has frst-hand factual information about the care and management of the patient. Generally, such witnesses If physicians are should not be asked questions intending to solicit an opinion about the work of others. If called to give physicians are called to give evidence as experts, their testimony will be expected to include an evidence as experts, opinion on issues relating to standard of care and causation. If you do not understand a question, ask counsel to repeat or rephrase the question. If physicians have questions about the procedure or the facts of any case, they should raise their concerns with legal counsel well in advance of being called to give evidence. Non-resident patients From time to time, physicians practising in Canada are called on to provide professional services to patients who are not ordinarily resident in Canada. Many such patients are visitors or tourists who are in need of urgent or emergent care. At an increasing rate, however, these are individuals, mostly United States residents, who have travelled to Canada specifcally to receive medical care and attention. Non-resident patients who may be dissatisfed with the professional medical services they received in Canada may consider bringing a medical-legal action against the Canadian physician. In some cases, they may try to have the action launched in the foreign territory where they reside. An issue will then arise as to whether the foreign court should accept jurisdiction or defer it so the action must be brought in Canada. The more it appears that a non-resident was encouraged or invited to attend in Canada for medical care or attention, the more it appears Before treating that arrangements for such care or treatment were made while the patient was in the foreign a non-resident jurisdiction, the more the care or treatment provided was elective, or the more it appears that foreign funding was involved, the greater the likelihood the foreign court will permit the legal patient (with action to proceed in that jurisdiction. Canadian physicians who treat non-resident patients in the exception of Canada may take steps to encourage any subsequent medical-legal actions to be brought in emergency cases), Canada. Physicians can do this by requiring that those patients submit to the jurisdiction and all physicians should law of the province in which the care or treatment is given. If a patient refuses to sign the form, physicians put themselves at risk if they carry the professional relationship any further.
They may be unable to recognize their own disabilities or evaluate their own behavior order augmentin once a day antimicrobial natural products. However cheap augmentin 375mg antibiotics for sinus infection, unawareness may lead to anger and frustration when the individual cannot understand why he can no longer work at the same job order augmentin 625mg amex herbal antibiotics for uti, or enjoy the same freedom as before. It is sometimes called “organic denial,” or anosognosia, and is a condition that may last a lifetime. Organic denial can be confusing to health professionals, friends, and family members who may interpret the individual’s unawareness of symptoms as a willful decision to ignore what is known to be true, when the reality is that the individual simply does not perceive that what is happening to him or her represents symptoms of a disease. In such a case, the focus should be on mitigating the individual symptoms without repeatedly confronting the issue of the underlying diagnosis. Where there is noncompliance with therapy or nursing care because of unawareness, it may be useful to develop a contract that creates incentives for compliance while sidestepping discussion of the diagnosis. Executive Effciency Executive functions involve the highest forms of cognitive processing. Executive functions involve fundamental abilities that regulate the primary cognitive processes in the brain. These fundamental abilities include (but are not limited to) speed of cognitive processing, attention, planning and organization, initiation, perseveration, impulse control, and other regulatory processes impacting cognition. Changes to cognition are part of a constellation of behavioral and personality changes that are referred to as the “dysexecutive syndrome” in Chapter 6, the Psychiatric Disorder, later in this book. It appears that the brain compensates for dysfunctional circuitry by using “effortful” processing to do tasks that were once automatic, and by recruiting alternate areas of the brain for cognitive tasks, all of which slows processing speed. Divided attention is needed to drive a car while listening to the radio, talking to other passengers or reading a map. For most people, divided attention is impaired when we are tired, sick, or stressed. Daily tasks, such as attempts to follow a recipe, to maintain a daily planner, to complete a list of household errands, or to fll out applications or forms may become diffcult and frustrating, leading to outbursts of irritation and emotion. Even those who never before used daily planners or computer calendars may need to start. A lack of initiation is often misinterpreted as laziness, apathy or lack of interest, and may be a reason for poor performance at work. Perseveration, or being fxed on a specifc thought or action, can occur when behaviors are inadequately regulated by the brain. For instance, travel out of town, or a visit to the doctor or dentist, may disrupt a safe routine. As symptoms of the cognitive disorder, these outbursts may be caused by the loss of impulse control, from confusion or feelings of being overwhelmed, from a disruption in the ability to track time, or by frustration that one’s needs (however reasonable or unreasonable) are not being met. Assessing for and treating a mood disorder may diminish irritability and temper outbursts. Identifying the underlying causes of irritability and temper outbursts may help diminish their frequency and severity. Caregiver reporting may be an important means of tracking outbursts and their severity. You may fnd that family members or caregivers wish to speak with you privately about their loved one’s irritability and emotional outbursts. While irritability often passes quickly, outbursts do have the potential to become violent. Safety should always come frst and caregivers should be encouraged to prepare an exit strategy for leaving the house or calling for help if an outburst threatens to get out of control. Treatment for irritability and temper outbursts are discussed in detail in Chapter 6, the Psychiatric Disorder, later in this book. Language Communication, or the transfer of information from one person to another, requires a complex integration of thought, muscle control, and breathing. In addition to speed limitations, the brain fails to regulate the sequence and amount of traveling information, resulting in impairments in starting and stopping. Even in later stages of the disease, language comprehension may remain when the ability to speak is signifcantly diminished. This fact is important to communicate to family members, staff at care facilities and other healthcare professionals. Most often people with early symptoms can continue to remain gainfully employed but will change jobs or move to a position that might be less demanding. Maintenance of employment requires that the person be fexible and willing to consider other levels of paid activity. The best indicators of being able to maintain an accustomed job, without a job change, are better performances on a task of psychomotor speed, fewer motor signs, and higher energy (less fatigue). The decision to retire or apply for disability is an important one that should be considered with input from occupational therapists, social workers, psychologists and physicians. Cognitive performances can be used to help counsel what jobs might be most readily completed with the least amount of stress, and the current family fnancial situation, as well as the activity and participation needs of the individual, must be considered. A modifcation of schedules and expectations is essential to maintain the highest levels of activity and performance, and to avoid depressed moods due to failures. Clinically, as the disease progresses, the severity of cognitive impairments increases and individuals are often unable to speak or communicate their views in late stages. For this reason an early discussion of communication devices, such as computerized speech production or letter board, or simple hand gestures, is essential. These memory problems, combined with the disruption to executive functioning and slowed mental processing caused by the disease, force the individual to rely on conscious memory systems to perform ordinary tasks, requiring immense concentration and causing fatigue, frustration and irritability. The cognitive disorder also manifests during the prodrome of the disease as impairments in emotional recognition, perception of time, smell identifcation, spatial perception and unawareness of symptoms. The physician should be alert for reports from caregivers about early changes to the speed and quality of thought and perception. Each task is allowed 45 seconds and the score is the number of items correctly read aloud. Findings reveal that intellect is in the superior range but learning and speed are in the average range. Neuropsychological feedback is given as well as strategies for compensation for supposed cognitive declines. One month later the man reports that he was able to modify his work schedule and duties to maximize his efforts and decrease his stress. Case Study: #2 The Cognitive Disorder: Initiation A 60 year old mother, living with her daughter, reported that her learning, memory and language were good, her mood great, and her interest in activities high. She enjoyed and cared about many things in her life but was disappointed that she “never did anything anymore. She was a good follower and enjoyed the activities that friends and family encouraged her to attend or participate in.
Researchers are very interested in this ‘pre-symptomatic’ period and have developed tests to look at the brain chemistry 375mg augmentin with mastercard antibiotics for uti pdf, function and structure at this time buy augmentin 625mg amex antimicrobial flooring. It is likely that any medication designed to slow down or prevent the diseases that cause dementia would work in this early phase cheap 625 mg augmentin mastercard antibiotic questions, before the disease is fully established. Over time, the changes in the brain will begin to cause mild symptoms, but which are initially not bad enough to count as dementia. Subtle problems in areas such as memory, reasoning, planning or judgement may cause diffculties with more demanding tasks (such as preparing a meal) but they will not yet signifcantly affect daily life. About 10–15% of people with this diagnosis will go on to develop dementia each year. There are some differences between the different dementias – Alzheimer’s disease, for example, seems to have the slowest progression on average – but much of the variation is from person to person. These include age – people who develop symptoms before 65 often have a faster 4 The progression of Alzheimer’s disease and other dementias progression. Evidence also suggests that a person’s genes play a role, as does someone’s overall physical health. People with poorly controlled heart conditions or diabetes, those who have had several strokes or those who have repeated infections are all likely to have a faster deterioration. On the positive side, there is some evidence that keeping active and involved can help a person with dementia retain abilities for longer. Some of these factors affect the underlying disease processes in the brain, while others do not but still help with dementia symptoms. Those supporting someone with dementia should help them to stay active – physically, mentally and socially. The person with dementia should also try to eat healthily, get enough sleep, take medications as advised and not smoke or drink too much alcohol. It is also important for the person to have regular check-ups (for eyes, ears, teeth and feet) and vaccinations, and to keep a careful eye on underlying health conditions. A sudden change in the person’s abilities or behaviour could indicate a physical or psychological health problem or an infection. Alzheimer’s disease Alzheimer’s is the most common type of dementia and the most studied. Progression of the other common dementias can then be compared with Alzheimer’s disease. Each type of dementia tends to have particular early symptoms, because different parts of the brain are affected frst. Later on, as damage spreads to more areas of the brain, the symptoms of different types of dementia tend to become more similar. By the late stage, the person will need a high level of care, whatever type of dementia they have. Early (‘mild’) stage Alzheimer’s disease usually begins with very minor changes in the person’s abilities or behaviour. At the time, such signs can often be mistakenly attributed to stress or bereavement or, in older people, to the normal process of ageing. It is often only when looking back that it is realised that these signs were probably the beginnings of dementia. The person will have diffculty recalling things that happened recently and also with learning new information. Someone with Alzheimer’s may: n mislay items around the house n forget recent conversations or events n struggle to fnd the right word in conversation or lose the thread of what is being said n become slower at grasping new ideas and unwilling to try out new things n become confused or lose track of the day or date n show poor judgement, or fnd it harder to plan or make decisions n have problems judging distance or seeing objects in three dimensions (for example, when navigating stairs or parking the car) n lose interest in other people or activities. If you are caring for someone with Alzheimer’s disease, there’s a lot you can do in the early stages to help them maintain their independence. It may be tempting to do things for them, but they are more likely to retain their sense of self-worth and independence if they are given the chance to do things for themselves, with support if necessary. They may experience distress over their failure to manage tasks and may need some reassurance. If this is the case, talk to them and give them as much emotional support as you can. Middle (‘moderate’) stage As Alzheimer’s disease progresses, the changes become more marked. They are likely to become increasingly forgetful – particularly of names – and may sometimes repeat the same question or sentence over and over. They may also fail to recognise people or confuse them 6 The progression of Alzheimer’s disease and other dementias with others. At this stage, the person might put themselves or others at risk through their forgetfulness, for example by not lighting the gas on the cooker or forgetting to take medication. Some people at this stage become very easily upset, angry or aggressive – perhaps because they are feeling frustrated or because they misinterpret what is happening – or they may lose their confdence and need a lot more support or reassurance. Other symptoms may include: n becoming confused about where they are, or walking off and becoming lost n muddling up time and getting up at night because they are mixing up night and day n behaving in ways that may seem unusual, such as going outside in their nightclothes, becoming very agitated or unknowingly behaving in socially inappropriate ways n experiencing diffculty with perception and, in some cases, having delusions (strongly believing things that are not true) or, less often, hallucinations (usually, seeing things that are not really there). Changes in behaviour tend to be most common from the middle stage of dementia onwards and are one of the most challenging aspects of dementia for carers. For more information about these symptoms and how to deal with them see factsheets 525, Changes in behaviour, 509, Dementia and aggressive behaviour, 501, Walking about, and 527, Sight, perception and hallucinations in dementia. Late (‘severe’) stage At this stage, the person with Alzheimer’s will need even more help and will gradually become totally dependent on others for nursing care. Loss of memory may become very pronounced, with the person unable to recognise familiar objects, surroundings or even those closest to them, although there may be sudden fashes of recognition. They may start to shuffe or walk unsteadily, eventually spending more time in bed or a wheelchair. The person may become restless, sometimes seeming to be searching for someone or something. They may become distressed or aggressive, especially if they feel threatened in some way. Angry outbursts may occur during close personal care, usually because the person does not understand what is happening. Those caring for the person should try not to take this personally – the person is not being deliberately aggressive. It is also important to consider that the person may be experiencing pain which they cannot express verbally. Although the person may seem to have little understanding of speech, and may not recognise those around them, they may still respond to affection and to being talked to in a calm, soothing voice. On average, people with Alzheimer’s disease live for eight to ten years after their symptoms begin. However, life expectancy does vary considerably depending on how old the person is and other factors as mentioned above. For example, people whose symptoms started in their 60s or early 70s can expect to live for around seven to ten years, whereas someone whose symptoms started in their 90s will, on average, live for about three years.
Once mites infest a large snake collection augmentin 375 mg low cost treatment for sinus infection uk, they may A question that has been asked many times is be impossible to totally eliminate buy cheap augmentin 375 mg online infection x box. We have very little information to determine whether ver- Managing a Collection tical transmission of this disease is possible buy discount augmentin on-line bacteria game. Typically, where there is one case not forwarded to the authors for substantiation. Snake owners in denial often decide that the agent can be transmitted to offspring; there- to conduct business as usual. What has made a difference in controlling and Present and Future Research Needs managing infectious disease outbreaks in domestic animals is 2-fold. Once the virus is puriﬁed and sequenced, speciﬁc primers against the viruses will be made and used in a polymerase chain reaction test. Western blot is another practical test that can be developed for making an antemortem diagnosis. Using Western blot technology, inclusion protein in small amounts obtained from biopsied tissue or isolated peripheral white blood cells from a blood sample can be tested. Studies to evaluate the sensitivity and speciﬁcity of the diagnostic testing methods described above are planned. J Zoo Wildl Med 25:511-524, 1994 pet trade, the need for such molecular-based tests is 3. Am J Vet Res 62:217-224, 2001 been inappropriate for the studies needed to have a 5. Vanncraeynest D, Pasmans F, Martel A, et al: Inclu- around the world is probably responsible for its sion body disease in snakes: a review and description spread. Jacobson E, Heard D, Isaza R: Future directions in reptile bling inclusion body disease of boid snakes. The aim of the leaflet is to provide you with detailed information about the condition. To view the online version of this leaflet, type the text below into your web browser: http://www. But most urologists suspect that it is under-reported, and may affect as many as 1 in 10 men (10%). This begins as a localised inflammation, which may then mature into a hardened scar. The scar is inelastic (stiff) and stops the penis stretching with erections, leading to the development of a curvature on erection. There are two erectile cylinders (corpora cavernosa) running along the penis (pictured). If the penis is abnormally squeezed or bent, the area where the septum attaches to the elastic fibres may over-stretch. In older men, reduced elasticity, disease of the arteries and diabetes all increase the likelihood of scarring after an injury to the penis. In most patients, the injury heals within a year and the plaque does not advance beyond its early inflammatory phase. In more persistent cases, the plaque is replaced by tough, fibrous tissue and may even form hard, calcium deposits. Peyronie’s disease can affect the penis by causing: • Curvature of the penis The inelasticity (rigidity) of the plaque means it cannot stretch as the rest of the penis does when you get an erection. A plaque on the top of the penis causes the penis to bend upward; on the underside, it causes a downward bend. In some cases, the plaque develops centrally, leading to indentation and shortening. Pain, bending, and emotional distress may then limit sexual intercourse; and • Erectile dysfunction (impotence) This occurs due the effect of the plaque reducing blood flow in the penis, but can also a loss of sexual confidence because of the change in shape of the penis. While most treatments can limit the effect of the condition on the penis, nothing can take the penis back to how it was before. The disease generally goes through two stages: • A painful, inflammatory phase This usually lasts for three to six months. There is no way to tell when the acute phase has ended, but easing of the pain usually heralds it; and • A chronic or stable phase You are usually in this phase at least 6 months after the pain has stopped. Two out of 10 men (20%) get a re-activation of the inflammatory phase, leading to more plaque development, and worsening curvature. In the remaining one out of 10 (10%), there may be spontaneous improvement in curvature without treatment. Although the plaque itself does not normally disappear completely, a new plaque can develop on the opposite side to the original one, leading to the penis straightening out. Peyronie’s disease sufferers usually seek medical attention in the acute phase because of painful erections or difficulty with intercourse. Providing education about the disease, and its likely course, is often all that is required. Nothing has been shown conclusively to make plaques disappear, or to limit their growth. Some tablets can, however, limit the pain in the early inflammatory phase, or improve the quality of the erection if that is the main problem. Most clinicians favour one type of medical therapy over another, although the evidence for all is weak. Potassium para‑aminobenzoate (Potaba®) tablets have the best available evidence for improving pain, but are not very well tolerated. Tablets such as sildenafil, vardenafil, tadalafil and avanafil can help by improving erectile dysfunction in Peyronie’s disease, and this may be all the treatment that is required. Traction devices Traction devices have been used during the painful, inflammatory phase to limit the development and impact of curvature. Using a vacuum erection assistance device twice a day for 10 minutes (or a penile extender traction device for six hours each day) can, over a period of three to six months, help correct some of the curvature. The main advantage of these devices is that any improvement in curvature occurs without penile shortening. Non-surgical options • Vacuum or traction devices These have been used in the chronic phase • Collagenase This is an enzyme that breaks down collagen (the main component of fibrous tissue). It is very effective in Dupuytren’s contracture, but the results in the Peyronie’s are less impressive. Most patients see an improvement in their curvature, the average being a reduction of 18°. It is best for those with lower levels of curvature (less than 50°), where a small level of correction avoids the need for surgery. Each injection costs approximately £600, with the current evidence from trials suggesting that between six and eight injections are needed. Surgical options The aim of surgery is to get the penis functionally straight penis (with less than 20° of curvature).