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Between the first meeting and the official launch of the Campaign in May 1989 buy cheap dilantin 100mg on line medications 247, the steering 11 committee met at the Ciba Foundation order 100mg dilantin with mastercard treatment lead poisoning, the academic front for the drug company Ciba Geigy. Professor Sir Hermann Bondi was influential within the British Humanist Association, and Sir Alastair Pilkington was at that time one of the principal directors of the Wellcome Foundation. The Ciba Foundation also plays host to a number of other organisations with which Caroline Richmond and Sir Walter Bodmer are associated. These include the Wellcome-administered Association of Medical Research Charities and the Association of British Science Writers. The British Association for the Advancement of Science holds meetings there for its Media Fellows, as does the Medical Research Council. In the February 1989 issue, Nick Beard contributed an article about the need to put natural or alternative remedies through clinical trials. Last year Nature published a paper which claimed to provide in vitro evidence for an effect which could have helped to explain homoeopathy — the start of the Benveniste fiasco. However, this was followed shortly afterwards by a damning report from a team of investigators who 13 found serious errors in the research methods involved, invalidating the research. When we arrived in Paris we found Dr Benveniste was not doing his experiments with his own hands but that somebody else was doing them for him in an exceedingly sloppy way. He was not actually taking proper account of the statistical controls that in those circumstances any first year undergraduate biologist would recognise to 14 be necessary. The Campaign proper finally got off the ground at a press conference held on May 8th 1989, at the Royal Society of Medicine. The campaign aims at promoting assessments of new treatments and protecting consumers from fraudulent claims. It will act as an independent information service for journalists who want 16 to comment on fraud in medicine, and it will also set up specific enquiries. The news content of the article simply reiterated basic information about the Concorde trials. For a self-styled independent organisation, the proximity of these articles, their intimacy even, was a little embarrassing. Even in this article, which described the new organisation and its launch, Thompson Prentice could not resist placing information from Wellcome in close proximity. I have a cluster of patients who have been convinced that homoeopathy and special diets will help them. Following the launch, Michael Baum gave an interview to the Journal of Alternative and Complementary Medicine. After the launch, Steering Committee meetings continued to be held at the Ciba l9 Foundation, the first being on the 15th of May. Vincent Marks, a sixty two year old medical doctor and Professor of Biochemistry, is the perfect professor for the end of the twentieth century: an age when intellectual endeavour has been turned into private property and the greatest accolades of learning are tucked away in bank accounts. In 1985, as a member of the British Association of Clinical Biochemists, of which he was 2 later to become President (1989-1991), Marks received the Wellcome Award for Good Laboratory Practice. Between 1985 and 1990, the Department of Biochemistry which Marks heads at Surrey University received over half a 3 million pounds in grants from Wellcome. At Surrey University Marks has built up the Biochemistry Department, and the Department of Nutrition, by linking up the work of his staff colleagues with lucrative grant-funding from the large food processing, chemical and pharmaceutical companies. For his own research work, Marks is adept at choosing funding bodies and has become an influential and experienced grant receiver from many powerful sources. He has attracted to the Department staff who have a good track record of working with industry; in November 1984, for example, Dr Juliet Grayf was appointed a 4 Lecturer in the Department. Marks has also attracted the major grant-aiding organisations in medical research. In 1989, the Breast Cancer Biology Group was established within the Biochemistry Department at Surrey. The location of the new group at Surrey maximised contact with the surgical, histopathological and breast screening teams already established at the Royal Surrey Hospital, 10 Guildford. It meant also that Vincent Marks was to work closely with the two major British cancer charities. Taylor studies deficiencies and over-exposure to toxicity; he is a member of a number of Department of Health working groups. He works in the Robens Institute for Occupational Health and Safety, which is responsible for researching industrial, occupational and environmental health. The Robens Institute is completely dominated by chemical and pharmaceutical interests.

Pheochromocytoma must be considered as a possible underlying etiology of his hypertension discount dilantin 100 mg with amex symptoms mononucleosis. His antihypertensive medication changes may also be contributory—perhaps clonidine rebound purchase dilantin 100mg without prescription medications resembling percocet 512. The presence of acute end-organ damage constitutes a hypertensive emergency, whereas the absence of such complications is considered hypertensive urgency. Examples of acute end-organ damage include hypertensive encephalopathy, myocardial ischemia or infarction associated with markedly elevated blood pressure, aortic dissec- tion, and pulmonary edema secondary to acute left ventricular failure. Hypertensive emergencies require immediate reduction in blood pressure over a few hours, typically with intravenous medications and close monitoring in an intensive care unit. Hypertensive urgencies also require prompt medical attention, but the blood pressure can be lowered over 1 to 2 days and can be monitored in the outpatient setting for patients with reliable follow-up. Hypertensive crises are uncommon but occur most often in patients with an established history of so-called essential hypertension, that is, hypertension without an apparent underlying cause. A crisis may be precipitated by use of sympathomimetic agents, such as cocaine, or by conditions that produce excess sympathetic discharge, such as clonidine withdrawal. Hypertensive crises also result from underlying diseases that cause hypertension, such as renovascular disease (eg, renal artery stenosis), renal parenchymal disease (eg, glomeru- lonephritis), and pheochromocytoma. Although the pathophysiology is not completely understood, abrupt rises in vascular resistance are met with endothelial compensation by the release of vasodilator molecules such as nitric oxide. If the increase in arterial pressure persists, the endothelial response is overwhelmed and decompensates, leading to a further rise in pressure and endothelial damage and dysfunction. In normotensive adults, cerebral blood flow remains relatively constant over a range of mean arterial pressures between 60 and 120 mm Hg because cere- bral vasoconstriction limits excessive cerebral perfusion. As the mean arterial pressure increases beyond the normal range of cerebral autoregulation, there is cerebrovascular endothelial dysfunction and increased permeability of the blood-brain barrier, leading to vasogenic edema and the formation of micro- hemorrhages. Patients then manifest symptoms of hypertensive encephalopa- thy, such as lethargy, confusion, headaches, or vision changes. The definition of hypertensive emergency does not require numerical thresholds of arterial pressure but is based on end-organ effects. Autoregulation failure can occur in previously normotensive individuals at blood pressures as low as 160/100 mm Hg; however, individuals with long- standing hypertension frequently develop adaptive mechanisms (eg, cerebral arterial autoregulation) and may not show clinical manifestations until the blood pressure rises to above 220/110 mm Hg. Thus, emergent treatment of hypertensive encephalopathy (and indeed all hypertensive emergencies) should focus on the symptoms rather than the numbers. In fact, it may be Right shift in chronic hypertensives Autoregulation failure Normotensive Cerebral 70 cerebral blood blood flow, flow mL/100 g/min Cerebral hyperperfusion 0 0 60 120 Mean arterial pressure (mm Hg) Figure 10–1. Chronic hypertensive patients have an adap- tive mechanism that shifts the curve to the right. As a consequence of the right shift in the autoregulation curve, these “normal” blood pressures may lead to decreased perfusion to the brain, result- ing in infarction, or similar renal or coronary hypoperfusion, and ischemic injury. Usually, a reasonable goal is reduction of mean arterial pressures by no more than 25% or to a diastolic blood pressure of 100 to 110 mm Hg over a period of minutes to hours. Treatment of hypertensive emergencies usually necessitates parenteral med- ication without delay; direct blood pressure monitoring with an arterial catheter often is necessary. One of the most commonly used medications for treating hypertensive emergencies is sodium nitroprusside. It has the advantage of nearly instantaneous onset of action, and its dose can be easily titrated for a smooth reduction in blood pressure. However, its metabolite may accumulate, resulting in cyanide or thiocyanate toxicity when it is given for more than 2 to 3 days. Intravenous loop diuretics and vasodilators such as nitroglycerin decrease the preload (cen- tral venous pressure) in acute pulmonary edema. Myocardial ischemia or infarc- tion is treated with intravenous nitroglycerin to improve coronary perfusion and beta-blockers to reduce blood pressure, heart rate, and myocardial oxygen demand. Patients with aortic dissection benefit from medications that reduce the shear forces affecting the aorta, which will help limit propagation of the dissec- tion.

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His blood pressure is elevated but asymmetric in his arms 100 mg dilantin fast delivery symptoms of colon cancer, and he has a new murmur of aortic insufficiency 100 mg dilantin visa symptoms 7dpo. All of these fea- tures strongly suggest aortic dissection as the cause of his pain. He is tall with pectus excavatum and other features of Marfan syndrome, which may be the underlying cause of his dissection. Learn the clinical and radiographic features of aortic dissection as well as complications of dissection. Understand the management of dissection and the indications for surgical versus medical treatment. In hypertensive patients with dissection, urgent blood pressure lowering is indicated to limit propaga- tion of the dissection. Aneurysms can occur anywhere in the thoracic or abdominal aorta, but the large majority occur in the abdomen, below the renal arteries. Sometimes referred to as a “dissecting aneurysm,” although the term is misleading because the dissection typically produces the aneurysmal dilation rather than the reverse. It receives most of the shear forces generated by the heart with every heartbeat throughout the lifetime of an individual. The wall of the aorta is composed of three layers: the intima, the media, and the adventitia. These specialized layers allow the aortic wall to distend under the great pressure created by every heartbeat. Some of this kinetic energy is stored as potential energy, thus allowing forward flow to be maintained during the cardiac cycle. One must consider the great tensile stress that the walls of this vessel faces when considering the pathologic processes that affect it. Cystic degeneration of the elastic media predisposes patients to aortic dis- section. This occurs in various connective tissue disorders that cause cystic medial degeneration, such as Marfan and Ehlers-Danlos syndrome. Other fac- tors predisposing to aortic dissection are hypertension, aortic valvular abnor- malities such as aortic stenosis and congenital bicuspid aortic valve, coarctation of the aorta, pregnancy, and atherosclerotic disease. Aortic dissection may occur iatrogenically after cardiac surgery or catheterization. A dissection occurs when there is a sudden intimal tear or rupture followed by the formation of a dissecting hematoma within the aortic media, separat- ing the intima from the adventitia and propagating distally. The presence of hypertension and associated shear forces are the most important factors caus- ing propagation of the dissection. It can produce an intraluminal intimal flap, which can occlude branch arteries and cause organ ischemia or infarction. The hematoma may rupture into the pericardial sac, causing cardiac tampon- ade, or into the pleural space, causing exsanguination. It can produce severe acute aortic regurgitation leading to fulminant heart failure. Differentiating the pain of dissection from the pain of myocardial ischemia or infarction is essential because the use of anticoagulation or thrombolytics in a patient with a dissection may be devastating. In contrast to anginal pain, which often builds over minutes, the pain of dissection is often maximal at onset. In addition, myocardial ischemia pain usually is relieved with nitrates, whereas the pain of dissection is not. Also, because most dissections begin very close to the aortic valve, a dissection may produce the early diastolic murmur of aortic insufficiency; if it occludes branch arteries, it can produce dramatically different pulses and blood pressures in the extremities. Most patients with dissection are hypertensive; if hypotension is present, one must suspect aortic rupture, cardiac tamponade, or dissection of the subclavian artery supplying the arm where the blood pressure is being measured. Often a widened superior mediastinum is noted on plain chest film because of dissec- tion of the ascending aorta. When aortic dissection is suspected, confirming the diagnosis with an imaging study is essential. Because of the emergent nature of the condition, the best initial study is the one that can be obtained and interpreted quickly in the given hospital setting. Several classification schemes describe the different types of aortic dissec- tions.

T he by-product o f governm ental response to self- actualization needs is the growth of service bureaucracies 100 mg dilantin amex medications quizlet. If well-being is a scarce commodity order dilantin 100 mg medicinenetcom symptoms, which is a plausible assumption, it is a new kind of scarcity. Society sought to alleviate scarcity by correcting inequities in income distribution and by at­ tacking the industrial monopolists’ control of the market. However, well-being can only be scarce when its delivery is constrained by bureaucracies and by providers. This will lead to consideration of a problem realized in the collectivist democracies many years ago. Monopolization of authority by bureaucrats led to the creation o f an official elite, which in turn discrim inated against those less entrenched in the bureaucracy or those outside. T he same kind of rigidities and discriminations m ight appear in the United States as it changes from an industrial to a service economy. If so, change from a subsistence to a well-being society will be accompanied by a struggle against different injustices. Service sectors often pursue internal objectives in derogation o f the public in­ terest. T he slow strangulation of New York City by those in control o f vital services—fire, police, sanitation—is a good example. And if all of this is so, a series of severe social, political, and organizational problems may erupt. Well-being services are produced by the great provider institutions: law, m ed­ icine, government, and so on. However, all these systems are in severe disarray and under strong pressure to change. At the very time we are moving from a m anufacturing to a service economy, the m ajor service systems are in a state of crisis analogous to that suffered by m anufacturing industries in the 1920s and 1930s. A rem edy for the crisis in medical services is being sought through federal financing—a na­ tional health insurance plan. T he assum ption is that gov­ ernm ental absorption o f the costs of care will redress access and distributional inequities. If a national health insurance plan is enacted, some o f the inequities may be curbed or modulated. T he underlying prem ­ ise of medical care financing reform is that medicine pro­ duces enough health to justify the enorm ous expenditure. A larger governm ental role, particularly through fi­ nancing, will strengthen and intensify professionalism in medicine, not weaken it as many providers have argued. A national health insurance plan will specify that only professional services can be bought. Con­ sumers with cash can buy virtually any service from any person or agency willing to sell it, subject only to the loose strictures of state licensing and certification laws. But with federal assumption o f the costs o f care, the care that can be bought will inevitably be the care that is already provided. This might not be an unhappy result if professionalization in medicine were an unvarnished good. But the goals o f pro­ fessionals are rarely the same as the goals of those whom they serve. The Crisis in Service Institutions 131 Professionalized service bureaucracies—health, education, police, fire, transport, and so forth—are not as responsive as most o f us think they should be. As services become profes­ sionalized, as most have, the service bureaucracy becomes less sensitive to social needs and m ore impervious to social controls. Few have questioned the need for each judge to have a private bathroom in chambers, nor the physician’s “right” to work when and how he or she wishes. More will question the sanitary workers when they allow garbage to pile up on the streets. T he m ore the public becomes subser­ vient to the professional, and the less the consum er gets for m ore money, the m ore will the public’s sense of helplessness grow.

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