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With the goal of starting to fill that gap buy levothroid 200 mcg without a prescription thyroid gland complications, questionnaires were sent to clinics and medical interpreter organizations in order to collect data on which variants were encountered and at what frequency discount levothroid 100 mcg with visa thyroid symptoms tingling. It should be noted that in that study the denomination lexical variant was used to refer to words or phrases used by patients that were neither the technical term nor the ‘standard’ buy levothroid master card thyroid disease and hives. The responses received not only confirmed the extent to which lexical variants are employed in the healthcare setting purchase levothroid 200 mcg on-line qigong thyroid gland, recovering a list of around 242 distinct variants, but also demonstrated a surprising diversity in terms of origin. The variants recorded in the survey by respondents as ‘lexical variants’ included ones with origins in other languages, including indigenous languages – such as cuate from the Nahua cóatl, meaning ‘twin’ – or the English language – for example, raite to mean ‘a ride as a form of transportation and rifill to mean a Dialect Variation and its Consequences on In-Clinic Communication 219 ‘medication refill’. However, it should be noted that most diatopic variants were found to be from Mexico, with high numbers also from El Salvador, Guatemala and parts of South America (Colombia and Peru). This concentration of variants from a handful of countries seems to reflect the composition of the non-English speaking Latino population in that region, which seems to logically imply that the variants most frequently employed are determined, in part, by the most common countries of origin for the Hispanic population in that region, leading us to hypothesize that care should be taken in generalizing these results to other sectors of the United States. Impact on care Given the presence and diversity of these variants in the clinic setting, the question is then raised as to if they have any impact on care. In early 2014, I met with groups of Spanish for healthcare professors, Spanish-speaking medical professionals and medical interpreters while conducting part of a larger study. Nevertheless, in terms of specific studies, there is no known research that looks specifically at Latin American variants in cross-lingual communication in the medical context. However, there are studies showing ample evidence of the noxious effect of dialect variation between medical professionals and patients who share a common maternal tongue (Wolfram/Cavendar 220 Ashley Bennink 1992, for example) as well as from anecdotal evidence (Bennink 2013b) and other related studies on the language barrier (including Yeo 2004 and Timmins 2002, among others), which both reveal the considerable impact dialect can have on doctor-patient interaction in terms of misunderstandings, patient dissatisfaction, physician frustration and loss of time dedicated to patient care. In terms of studies regarding same language communication in the medical context, it has been well-confirmed by researchers such as Mishler (1984) and Woods (2006), to name two, that differences in language usage between doctors and patients who share a native tongue can result in miscommunications. This lifeworld language is the everyday language used by those unfamiliar or uncomfortable with medical terminology and includes aspects such as dialect variants, and euphemisms and even different definitions for technical medical terms (such as the difference between the lay definition of depression and the technical one). Though in this case, while the doctor is likely to understand the patient, the patient may not always be familiar with the medical language of the doctor. However monolingual English-speakers may also encounter communication difficulties on top of those arising from the lifeworld- medical language dichotomy. In conversations with medical profes- sionals, many have cited their difficulties in understanding certain re- gional dialects or the African American vernacular. Hoejke (2011: 11) affirms: “Monolingual English speakers from one geographic area of the United States also may not understand the local expressions and pronunciation of the patient population where they do their residencies”. For that reason, there are, as she mentions, some residency programs that offer acculturation Dialect Variation and its Consequences on In-Clinic Communication 221 courses to their first year residents even though they are native to the United States. The language taught in the course includes words and phrases used by the local patient community regarding various topics such as parts of the body, symptoms, sicknesses, etc. In this case, as opposed to the first monolingual scenario des- cribed, the physician’s role as an interpreter would no longer be suffi- cient to attain understanding, as he or she is now the one confronted with an unfamiliar language use. Nevertheless, since they still share the same base language and similar cultural backgrounds (at least in comparison with foreigners and speakers of another language), it is still not quite the same as the situation that we are confronting. Instead, dialect variants can represent an even more crucial factor when considering the communication between speakers who do not share a native language and thus have fewer resources available to them to resolve misunderstandings. An example of a cultural difference that can complicate the process would be the value of respeto, which can lead patients to show agreement with the medical professional even if they do not agree or do not understand. For example, one Latino patient at the clinic where I previously worked who spoke no English nodded “yes” to the medical professional when asked “do you speak English? It was only after speaking with the patient another five minutes in English that the physician realized that the patient was constantly nodding along to what the medical professional said or asked but actually had no idea what the physician 1 was saying. Other cultural factors that can impede linguistic communication may include differing beliefs on origins of illness, how care should be carried out, effective treatments, etc. Additionally, the stress of not knowing how to act in a setting that is not their own as well as being ill can make it harder for patients to think through their word choice and also can lead them to revert back to their native language or dialect (Marcos Marín/Gómez 2008). Thus some patients who are unable to reword what they wish to say, instead may respond to the 1 This tendency is also noted by other researchers such as Calzada et al. Aggravating this, in the case of the United States, is that courses and manuals have focused on teaching doctors and interpreters the technical and standard terminology required to communicate with La- tino patients while maintaining the formal register characteristic of the medical setting. Nevertheless, these terms may not be known nor fa- miliar to the Spanish-speaking patients whose lifeworld language may differ greatly from the standard. Additionally, these patients may use language and terminology from their lifeworld language or linguistic repertoire that is likely to be unfamiliar to a Spanish as a second lan- guage learner. The resulting effect is an increase in misunderstandings and frustration, and decreased patient satisfaction and compliance – all of which impact quality of care and outcomes and all of which are fur- ther exacerbated by time constraints placed on patient care (Bennink 2014). An anecdotal example of how misunderstandings arising from differences between lifeworld and technical language can impact care would be the phrase commonly used in the city where I worked as a medical interpreter in North Carolina: mi esposo me cuida. This knowledge changed, in some cases, the doctor- patient communication, inciting a conversation regarding more reliable forms of birth control in the first case rather than assuming an adequate method was being used. Dialect Variation and its Consequences on In-Clinic Communication 223 addition to misunderstandings, lexical variants can have other possible consequences, including physician frustration and loss of patient satisfaction. In the previous example, it was mentioned that some Latino patients are reticent (or at times unable) to offer an explanation for a term they used when it is not understood and, instead, tend to 3 simply repeat the term or phrase. This repetition and difficulty to resolve what the patient wishes to express can be frustrating for the medical professional who does not always understand the difficulty in explaining something in another way and also feels the pressure of limited patient care time. Additionally other studies, such as those by Timmins (2002), Yeo (2004) and David/Rhee (1998) note that when a patient feels misunderstood their levels of satisfaction and trust in their provider decrease and, in turn, this often results in poor patient compliance and, consequently, less positive health outcomes. A recent study published in the Journal of Internal Medicine affirmed that doctors in the United States have only about eight minutes per patient (Block et al. Also, given that medical interviews with speakers of another language generally take longer than a standard interview, providers often feel pressured from the start. Moreover, the relative lack of these terms in bilingual dictionaries and reference materials (Bennink 2013a) exacerbates the situation and leaves the doctor without the needed support to help him/her quickly resolve the situation. An additional concern regarding the loss of patient care time is that, if the doctor has to spend more time resolving an unfamiliar term, he/she may feel rushed, which could give rise to more errors and/or a decrease in quality of care. Necessary communicative competence Given the appearance of dialect variants in clinic and their impact on communication and care, the communicative competence necessary for this setting will now be examined. Effective communicative competence on the part of the medical professional would, first, imply not only a knowledge of technical terminology but also an ability to communicate with the patient on a more human level that reduces the social distance as well as using language that allows the patient to understand the information the doctor wishes to explain. This is the productive element of the communicative competence, that is, the linguistic ability to produce certain lexicon during the medical interview and to carry out an effective and appropriate dialog. Second, medical professionals would need the receptive capacity to understand variants used by patients as well as a practical knowledge of techniques that could be implemented to resolve a misunderstanding in the case that one should occur. Thus, specifically in terms of lexicon, the medical professional needs to produce the appropriate standard and technical terminology while at the same time understand the variants used by patients or at least be equipped with the skills to help attain a level of understanding with the patient (Bennink 2013a). Unfortunately, though in theory this concept is fairly basic, there are various challenges to its practical implementation that arise from diverse factors including the patient himself/herself, the inherent characteristics of the variants and the availability of materials and education. In the above description of communicative competence, the onus of fostering adequate communication is placed solely on the medical provider, a considerable burden for a single person who interacts with people of various backgrounds on a daily basis. Firstly, the patient typically uses a given variant as opposed to a more standard term because that is the one he/she has within his/her language repertoire. Secondly, the Dialect Variation and its Consequences on In-Clinic Communication 225 patient, in most cases, will have a lower ability to resolve misunderstandings than the medical professsional due to a couple of factors. For one, it has been demonstrated that people with a low educational level and socioeconomic status tend to have more difficulties in resolving misunderstandings or finding other ways to explain a word or a phrase. This may result in the patient’s inability to play an active role in the resolution of misunderstandings leaving the respon- sibility on the medical provider, who then has to learn to effectively resolve these situations with each patient from diverse backgrounds 4 and countries of origin.

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The responsibilities and obligations include The medical order levothroid 50mcg on-line thyroid zapper, scientific buy levothroid with paypal thyroid gland physical exam, regulatory and marketing knowledge of the elements of informed consent discount levothroid express thyroid vomiting, opinions must be weighed and balanced in the the role and responsibilities of institutional review plans generic levothroid 100mcg with visa thyroid cancer survivor tattoos. Understand and Conceptualize All sponsor staff have a specific and direct re- Clinical Study Design sponsibility for the safety and welfare of subjects participating in clinical trials. This group of the investigational product; and a clear rationale assesses the overall study design and ability of the for the dosage and dosing interval. The quality of a clinical protocol ogy findings; the investigational product±disease can be assessed by how well the elements of the relationships; the international regulatory require- protocol are prepared. The sponsor is usually Subjection selection criteria responsible for developing the protocol in industry- Screening procedures for entry Study parameters sponsored clinical trials. How adverse events are managed ment of the reasons for conducting the study and and recorded are particularly important to the spon- the basis for the dosage selection and duration that sor and regulatory authorities. Quality protocols should should ensure that the study defines the criteria for target relevant information in the background and success or failure of treatment. Objectives must be specific and capable subjective, then methods to prevent observer bias of answering a key clinical question required by the (so-called ``observer truing') must be employed. Good protocols always include, in addition, The schedule of assessments describes a schedule of adequate compliance checks of drug consumption time and events and provides a complete profile by the subjects of the study. Good quality schedule Protocols should predetermine how subjects will of assessments sections also include acceptable be replaced following dropping out of the study. These estimation; investigational product packaging principles include the concepts of standardization time frames; protocol-specific and country-specific and minimization. In supplies; investigational product supply tracking addition, standardization facilitates the monitoring systems; investigational product ordering and process and therefore increases accuracy of the packaging processes; general investigational prod- data. While efficiency is an important variable in uct formulation and packaging processes and con- the design process, the systems must also be suffi- figurations; protocol design; randomization ciently flexible to account for the variances between procedures; and investigational product dispensing projects. Some objective measure of the availability of the Many physicians may need to be considered correct patient population is important during a before the best investigators can be identified. The purpose of the study initi- Of primary importance to the investigator is the ation meeting is to orientate the study staff to the rationale for use of the drug and the expected safety requirements of the protocol. The protocol should be explained, must ensure that the study medication and mater- including the requirements for the patient popula- ials are available at the site. To be a successful monitor, the sponsor repre- sentative should know: how to interpret hospital/ subinvestigator(s), the study coordinator or re- clinic records/charts, laboratory tests, and inter- search nurse, pharmacist, and laboratory personnel pretations; has to query resolution procedures; or specialists as needed. Procedures for subject enrollment are addition, a monitor needs to have excellent inter- particularly important, since this is the area which personal communication and problem-solving may cause the most problems for the site. Conducting Clinical Trial Monitoring Clinical trial monitoring includes those activities The frequency of clinical monitoring depends on that ensure that the study is being conducted the actual accrual rate of the patients. Monitoring permits an studies may need to be visited more frequently, in-process assessment of the quality of the data depending on the accrual rate of subjects, the being collected. Monitors Following a monitoring visit, the monitor will ensure that the study is conducted, recorded and prepare a monitoring report for sponsor records reported in accordance with the protocol. The monitor reconciles investigational Local affiliate name Expiry date product shipped, dispensed and returned; arranges for shipment of investigational product to core country or investigative sites; checks investiga- supplies are being kept under the required storage tional product supplies at site against enrollment conditions. Failure to do so can result product inventory problems; implements tracking in some of the data having to be discarded during system for investigational product management on statistical analysis. This issue can prove to be prob- a study and project level; arranges for the return lematic when a single site is studying patients at and/or destruction of unused investigational prod- different locations. Finally, the double-blind code uct supplies; and ensures final reconciliation of must not be broken, except when essential for the investigational product supplies. Drug packaging should follow as consistent a Management of safety is a principal responsibil- format as possible within a project and must be ity of the sponsor monitor. Regulatory docu- sponsibility for informing the investigator about ments required for investigational drug use in the the safety requirements of the study. Drug supplies should be rec- changes from baseline with expected pharmaco- onciled and the integrity of the double-blind logical effects, acute and chronic effects and mul- treatment codes should be confirmed. In multicenter about the event to headquarters within 24 h and trials, a single lead investigator may sign a pooled headquarters will get the information to the drug study report. Presents the detailed efficacy the annual report must be written in a clear, concise findings, including the intent-to-treat analysis manner that accurately summarizes and interprets population and the efficacy data listings. Presents the detailed safety find- vide clear, simple graphs, tables, and figures to ings, including the intent-to-treat analysis illustrate and support safety findings. What is needed to get a drug Fourth, the chapters on Phase I clinical trials and approved is not the same as what is needed to make pharmacoeconomic research have been written by that drug into a commercial success. The typical pharmaceutical velopment, how this is done, and what preclinical physician has usually paid little attention to these information is needed in order to carry it out. Pharmaceutical physicians, spe- view regulatory affairs as the implementation of cialized though they may be in one discipline or their clinical development plans (and probably another, are well-advised to keep an observant eye vice versa), the proper constraints imposed by regu- on the interactions between their own and other latory authorities are so fundamental that they de- company departments. From the cellular stage, the re- searcher next defines specific molecular targets, An outline of the thought processes involved in such as receptors or cellular enzymes that comprise designing and implementing a Drug Discovery pro- the destructive phenotype. This chapter Researchers will target systems which are will discuss the process, and give practical examples affected by, or may be directly involved with, a from contemporary drug discovery scenarios. The treatments arising from All drug discovery projects depend on luck to these types of approaches can be palliative, or be successful, but research and careful planning can may find a market or need as disease-modifying improve chances of success and lower the cost. Prime examples of palliative therapies are Project teams can streamline the discovery process drugs designed to alleviate side effects of treatment by mapping the most direct methods that will yield with toxic chemotherapeutic drugs, such as nausea a discovery. In these cases, drug discovery scien- biology, chemistry, robotics, and computer simula- tists search for drugs which alleviate each symptom tions, years can be eliminated from the search for as if it were an isolated pathology. The costs of getting a new therapeutic Disease-modifying drugs are those which directly into the marketplace in 1997 were estimated at affect the primary disease. In many cases, prelimin- from a particular receptor in normal cells, but are ary research has been published on several aspects mutated, and thus are constitutively active or con- of the pathology. Is there an anomaly in a cell derived from a ations in the cellular architecture required for tumor, to use a cancer example, which renders that mitosis (cytoskeleton and cell motility). Unless a company can work faster or Hypothetically, because we also know that ster- better than the competition by taking a direct ap- oids, a currently used therapeutic, works by inhib- proach, it is, perhaps, a better strategy to approach ition of gene expression of many of these mediators, the target identification issue less directly. Are the transcription mechanisms known, seek to inhibit transcription factor activation by and if so, are there any other required enzymes or phosphorylation or proteolysis, while another proteins which are regulated by those same mech- group seeks to inhibit the binding of the transcrip- anisms? The real work comes in families with patterns of hereditary disease, and sequencing and identifying these genes, and ascer- mapping the transmission of the disease to find taining which are the unknown, novel sequences. The are then used in functional assays to prevent a Human Genome Project is a consortium of govern- response thought to be critical for disease develop- ment and industry-funded laboratories, which se- ment. Genomics and New Target Identification At the time of writing complete genomic se- quences are available for atleast 141 viruses, 51 Drug companies have recently become involved in organelles, two eubacteria, one eukaryote and the use of genomics to identify new genes which most mammalian mitochondria. Mo- for which complete genome data are available in- lecular biologists can seek mutations or alterations clude Haemophilus influenzae, Mycoplasma geneta- in genetic signatures which are predictive of the lium, and Saccharomyces cervisiae.

A selection of articles from the media addressing the same issues is listed in Appendix 2 buy levothroid 50 mcg cheap thyroid white tongue, in order to cast light on differences between the institutional discourse and the media discourse buy levothroid 200 mcg lowest price thyroid symptoms groin pain. Whereas Bhatia’s 140 William Bromwich (2005: 46) work on philanthropic fundraising analysed letters sent out for charitable causes proven levothroid 200 mcg thyroid symptoms causes treatment, this study focuses on another form of philanthro- py buy 200mcg levothroid thyroid or anxiety, blood donation, and the discursive resources used to promote it. For present purposes the focus will be on the promotional materials, though a selection of texts relating to the remaining three rhetorical purposes will also be considered where relevant. The study started from the preconception that altruism would in all probability be the sole argumentative strategy, but a systematic analysis of the data does not support this hypothesis. In many cases the authors of the material opt for a judicious mix of altruism, self-interest and en- lightened self-interest, reflecting their own perception of public opi- nion, but in the institutional discourse in most of the national cases The Gift Relationship: Cultural Variation in Blood Donor Discourse 141 under examination an appeal to altruism prevails, albeit not as the only discursive resource employed by professional healthcare writers. A brief overview of elements of altruism in the various national settings will now be given, with the references for each of the excerpts listed in Appendix 1. The Australian Red Cross, with a dialogic question-and-answer format, foregrounds altruism while providing scientific and technical information, including the fact that blood products are used not just for transfusion but also for the production of life-saving immunisa- tions, thus including an oblique reference to enlightened self-interest, as the potential donor is also the potential beneficiary of vaccinations. The use of the first person pronoun is evidently intended to involve the reader as an active participant and as a potential donor capable of empathy towards those in need of a blood transfusion: (1) Why should I give blood? In order to provide fresh blood products for treatments of patients with chronic diseases or in need of surgery because of illness or accident, we entirely count on the generosity of our blood donors to donate on a continuous basis. In the case of Ireland, altruism is the overarching principle, though the mention of “our hospitals” (inclusive we) and the various factors giving rise to the need for transfusions could be interpreted as enlightened self-interest, with altruism being tempered by self-preser- vation: 1 < http://www. The Gift Relationship: Cultural Variation in Blood Donor Discourse 143 (7) Irish Blood Transfusion Service Giving blood makes it possible for many people to lead normal healthy lives. Every year thousands of patients require blood transfusions in our hospitals, because they are undergoing surgery, recovering from cancer or have been in a serious accident. The donor will pro- vide a gift that is a lifesaver, saving up to three lives with one dona- tion and making a difference in the community, while connecting with fellow ‘Kiwis’: (10) Why should I donate blood 144 William Bromwich It isn’t every day you can do something to save someone’s life - but that’s ex- actly what you do every time you donate blood. Your blood donation could help save the life of an accident victim, a patient with severe anaemia, a person undergoing major surgery or even a newborn baby. Al- truism is key to blood donation efforts in Sri Lanka, a particular kind The Gift Relationship: Cultural Variation in Blood Donor Discourse 145 of altruism associated in the official discourse with Buddhist values, particularly generosity. Donation is construed primarily as a collective act timed to coincide with and celebrate Full Moon Day, an annual re- ligious holiday, rather than conceptualised as an individual medical procedure as in Western countries. Sri Lanka has eliminated the prac- tice of collecting from what Titmuss called ‘paid donors’: all blood donations now come from voluntary donors: (13) Sri Lankans attach special importance to the act of blood donation. The day also coincides with Poson Poya (Full Moon Day), an annual religious holiday that marks the arrival of Buddhism in Sri Lanka and is a time for generosity and celebration. One possible explanation for the al- most complete lack of argumentative discourse and the prevalence of informational content is that Sweden has managed to recruit five per cent of the adult population as donors, that compares extremely well with other countries (the figure for Iceland is 2. Donated blood is a lifeline for many people needing long-term treatments, not just in emergencies […] Ever since a national blood service was first created in 1946, we have relied on the generosity of blood donors […]. A ‘special reason’ may be an oblique reference to altruism, but potential donors are not required to donate for altruistic reasons, as other reasons will do just as well. With limited space given to altruistic motives, the psy- chological benefits for the donor are a recurrent theme: (17) I’m a Red Cross blood donor that won’t give up. Most healthy adults are eligible to give blood, however, there are some rea- sons a person may be deferred from donating temporarily, indefinitely, or per- manently. Your blood donations help treat cancer patients, traumatic accident and burn victims, newborn babies and mothers delivering babies, patients undergoing surgery, and many more. This lends further weight to Bhatia’s argument The Gift Relationship: Cultural Variation in Blood Donor Discourse 151 that to achieve an adequate characterisation of a particular genre, the institutional setting should be taken into account. A decision to donate your blood can save a life, or even several if your blood is separated into its components – red cells, platelets and plasma – which can be used individually for patients with specific conditions. Enlightened self-interest In a number of cases there is an appeal to potential donors to reflect on the fact that one day they themselves may need blood donated by others. En- lightened self-interest features prominently in the South African ap- peal: 152 William Bromwich (31) You could be next It’s not a nice thing to consider, but the fact is that you, a close friend, or a family member could well be the next car accident victim or surgery candidate requiring a transfusion. Unlike blood donated to the Red Cross or the Armed Services, it is not allocated to a national blood bank: (32) Giving Blood Saves Lives Your donation will help ensure an adequate supply for both children and adults who are patients within Lee Memorial Health System. Here the line between donors and recipients is blurred: they are no longer conceptualised as separate categories but as a fuzzy set (Lakoff 1987: 22), since donors may themselves need donations in the future. This brings to mind Malinowski’s (1922: 167) observation about gifts and counter-gifts in the Western Pacific as “one of the main instruments of social organisation […] and the bonds of kinship”. Self-interest It was initially expected that the institutional discourse would focus entirely on an appeal to altruism but this expectation was not con- firmed by the data. The following list of reasons to give blood begins with the offer of free juice and cookies, and conti- nues with other supposed benefits such as the chance to lose weight and to be excused from heavy lifting, before reaching the point where the donor is placed “on an equal footing with the rich and famous”. Paradoxically, an act that seems to be emblematic of altruism is moti- vated by a long list of self-centred considerations: (35) Top 10 Reasons to Give Blood The American Red Cross is constantly encouraging people to donate blood. It’s easy and convenient – it only takes about an hour and you can make the donation at a donor center, or at one of the many Red Cross mobile blood drives. The same line of reasoning appears on the Knoji Blood Donation web- site: (36) Donating Blood Is Healthy From a health standpoint, I can’t think of a better way for people with high blood pressure, migraines, or high cholesterol to let go of some waste. I do it to help with my blood pressure and migraines, as unloading two pints of blood [sic] is the best way for me to relieve pressure in my brain and my body. According to studies published in the American Journal of Epidemiology, blood donors are 88% less likely to The Gift Relationship: Cultural Variation in Blood Donor Discourse 155 suffer a heart attack. Urging people to donate blood more often, Harsh Vardhan said: “Regular blood donors, according to medical researchers, are 80 per cent less prone to diseases like heart attack, cancer, etc. Strands of argumentation in the discourse In each of the institutional appeals an attempt was made to identify the predominant strand of argumentation and the results are set out in the following matrix diagram. Although the discourse of altruism (upper left-hand quadrant) is predominant, the discourse of self-interest (up- per right-hand quadrant) also plays a significant role, and enlightened self-interest (lower left-hand quadrant) is also well represented, along with a strand focusing on organisational, scientific and technical is- sues (lower right-hand quadrant). Whereas in the institutional discourse there was a focus on altruism as the main motivation for blood donors, with some atten- tion to enlightened self-interest and organisational, scientific and tech- nical information, in the media reports the focus was primarily on self- interest, mainly considering the health benefits for the donor rather than the recipient. Concluding remarks This study investigated aspects of argumentation in the institutional blood donor discourse of a number of English-speaking countries and states, examining the strands of discourse based on altruism, en- lightened self-interest and self-interest. Institutional and cultural varia- tions were identified, not simply reflecting different national contexts, as in some instances cultural variation was identified also within the same national context. A stark contrast was evident between on the The Gift Relationship: Cultural Variation in Blood Donor Discourse 157 one hand the discourse of the institutional actors, in which altruism tends to prevail, along with elements of enlightened self-interest, and on the other hand the media reports, where self-interest clearly predo- minates. Healthcare professionals seeking to identify a judicious mix between the various motives to persuade blood donors to come forward to become regular donors might wish to compare their discursive practices with those characteristic of media reports as some mutual learning appears to be possible. Regardless of the specific approaches in the various national contexts, it is evident that public health information professionals need to continue to pay close attention to blood donor issues, also exploring the possibilities 3 afforded by social media. To conclude, the ongoing need for effective public health information is evident in this quotation from the Yelp review by a San Diego blood donor who was ‘weirded out’ not by the needles or the blood, but by the ignorance of potential donors: (40) I gave blood on one of their busses today. Introduction In the last two decades, Applied Linguistics and Translation Studies can be said to have experienced a similar shift: both disciplines have increasingly extended their focus of attention on social questions. It is true that the purpose of Applied Linguistics has always been “to solve or at least ameliorate social problems involving language” (Davies 1999: 1): but it is especially with the relatively new branch of Critical Applied Linguistics that issues such as identity, sexuality and power have become central questions to be addressed (Pennycook 2004: 785). Similarly, also Translation Studies have been more and more concerned with social factors involved in translation, with the translator’s social responsibility and issues of translation ethics (see for instance Pym 2006, Baker/Maier 2011). The ‘ethics of difference’ (Venuti 1998) has become a fundamental concept which has opened up many new lines of enquiry and has also influenced the authors of the present chapter.

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When returned to the body order levothroid visa thyroid nodules disease, these immune-enhanced cells would attack infected or cancerous cells buy levothroid 50 mcg with amex thyroid symptoms cold. He moved to the Department of Medicine and began working under the supervision of Professor J buy cheap levothroid 200mcg on-line thyroid cancer whole body scan. In 1985 buy levothroid discount thyroid ke symptoms, Sultan published his first abstract, for an international conference on leukaemia in Holland. His premise at that early stage was that the immune system had to be activated in order to attack the virus. Later, Jabar Sultan was frequently told that the genetic material of the virus was more likely to bind to the genetic material of cells produced during the process of activating the immune system. If the immune system cells were to be stimulated to attack the virus, then this had to be done in the presence of a factor mat also inhibited the virus from binding and replicating. Later he changed his mind, believing that it was probably more beneficial to try to use natural material to obstruct the replication of the virus. In late 1986, Jabar Sultan had worked out his first protocol for in vitro tests on immune cells. The new head of the medicine department, where he was continuing to write up his PhD, knew little about immunology and put Sultan in touch with Dr Anthony Pinching for advice. It appears, however, that Dr Pinching did nothing to suggest ways in which Sultan might further his understanding of the subject. Nor did Dr Pinching offer any help on subsequent occasions when both Jabar Sultan and Dr Sharp went to see him. All the doctors at the meeting agreed to take part in carrying out pre-clinical experiments. In 1986, Jabar Sultan attended a conference in Florida to present his work on cancer. Some time after his first visit to Dr Pinching, Jabar Sultan contacted his previous supervisor, Dr Sharp, who was now working at the London Bridge Hospital. He asked if there was any possibility of continuing his work on cancer patients at one of the hospitals where Sharp was a consultant. Money which Dr Sharp had obtained for Brownings enabled Jabar Sultan to build an advanced laboratory at the Hospital. Jabar Sultan was insistent that any such trial would have to be given to patients while they were resident in the Hospital and not simply attending consulting rooms. Jabar Sultan and Dr Sharp disagreed about this, principally because residence in the Hospital normally entailed considerable cost. Sultan insisted this was important because the treatment was experimental and if anything should happen to a patient, a fully-equipped intensive care unit should be accessible. There was no argument over the next important matter, that any such trial treatments should be given to patients free. In 1989, both were still alive and their referring doctor was able to say that they had suffered no adverse results from the treatment. Contrary to what Campbell was to say, one London patient was relatively well, and happy with the treatment, the other was less well, but did not complain about the treatment. The American patient wrote to Barker: Since treatment in September 1988, administered under the supervision of Dr Sharp... My doctors here continue to monitor my blood profile bi-monthly, testing both T-cell counts and percentages... There was no reason why any of these first three patients should have harboured any ill-will towards Dr Sharp. Both had received their treatment free and neither of them appeared to have suffered any deleterious affects. In fact no one other than Duncan Campbell had ever suggested that adoptive immunotherapy had adverse reactions. When Sultan returned from Japan, Dr Sharp and he approached Dr Pinching once more and informed him of their observations. Jabar Sultan was to say that Pinching was if anything even more definite than before. The attention of the press was drawn to the abstract of the paper given by Sultan in Japan, 22 and in December the Daily Express carried an article about the tests. He even went so far as to ring the Express complaining that he was never consulted about the article and advised on the correction of errors. At best, the treatment was inhibiting the virus, and hopefully directing the immune-strengthened cells against the cells that harboured the virus. The Express article was picked up by a number of other papers, which published short articles. Both men wanted to continue with the work, but money would increasingly become a problem. At a meeting of the Committee and then later in writing, Dr Pinching reiterated his lack of faith in the work of Dr Sharp and Jabar Sultan and suggested that some of their proposed techniques might be hazardous. The lack of side effects is encouraging, as are, of course, the clinical responses. Because Sharp was aware that Brownings was in a dire financial state, he made a unilateral decision, which was later to rebound on Jabar Sultan and Philip Barker, to charge these patients for their treatment. Sharp was painted as a mercenary and callous man charging vulnerable people for a course of treatment which was ultimately to kill them. In the event, neither the patients nor their relatives actually paid any money to Brownings. In fact, Jabar Sultan reported that both cases had shown some short-term improvement after the treatment. The implication of this omission is very serious because Campbell gives the impression that their deaths were hastened by the treatment which Dr Sharp gave them. Dr Sharp and Jabar Sultan had looked for a doctor who, in order to offset costs, would agree to patients being treated in their hospital and be monitored by their own consultant. In early August 1988, Dr Sharp and Jabar Sultan had a meeting with Dr Gazzard in the Endoscopy Unit at the Westminster Hospital. Of the two new patients, one was very seriously ill; she had lost her memory and was unable to walk. According to Jabar Sultan, both patients were clinically improved following their treatment. The first patient began to remember more and started going out from the hospital for walks. Jabar Sultan remembers vividly the moment when she kissed her husband, and thanked him for donating his blood to her. While co-operating with Dr Sharp on the management of these two patients, Dr Brian Gazzard appears not to have expressed any dissatisfaction with either the form or the content of the treatment, to Dr Sharp or his locum at that time, Dr Keel. If any of these doctors had doubts about the ethics of Dr Sharp, during this period, they were bound to report him to the General Medical Council. If they suspected that Dr Sharp was, as Campbell suggests he was, killing patients, they should have reported the matter to the police.

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Those with multisystem trauma purchase levothroid with amex thyroid gland medication side effects, neurological findings and those with suspected unstable fractures will require management at a major trauma unit buy 100 mcg levothroid thyroid gland ultrasound. Tips from the field • Routine use of a bougie for endotracheal intubation will mitigate C-spine manipulation • Exclude other causes of shock before attributing hypotension to neurogenic shock • Pregnant women secured to a long back board should be elevated on theirright side by tilting the board 15–20 degrees and placing pillows or blankets beneath Figure 14 purchase levothroid online now thyroid gland location in human body. Because it is narrower it reduces the lateral movement that may occur if a child is immobilized to an adult immobilization device cheap 50 mcg levothroid free shipping thyroid function. Additional Further reading shoulder padding is provided to compensate for the relatively large occiput of the younger child. International Trauma Life Support for Prehospital Care Providers, A degree of improvisation may be required to adequately 6th edn. The reliability of prehospital clinical immobilize a child for transport in the absence of a paediatric evaulation for potential spinal injury is not affected by the mechanism of immobilization device. Multicenterprospectivevalidationof crash, infants in a car seat may be immobilized in the seat as long prehospital clinical spinal clearance guideline. Low risk criteria for cervical- apparent injuries that would require removal from the car seat. Introduction In Western countries abdominal injury is present in around one- fifth ofmajortraumacases. Themajority aretheresultofroad traffic collisions and frequently occur in the presence of other injuries. A high index of suspicion is required in order to recognize occult injury and manage it appropriately. Mesen- teric tears are the commonest of these injuries, typically injuring the Up to 25% of serious abdominal injuries will be undetectable ileocolic vessels. Haemorrhage may occur acutely with the devas- by clinical examination in the early stages (50% if the patient is cularization of associated bowel leading to delayed necrosis and unconscious). Significant abdominal compression, particularly with the use of lap belts, may also result in pancreatic, duodenal or Blunt trauma diaphragmatic ruptures. The kidneys, liver and spleen are particularly vulnerable to Theprevalenceofpenetratingtraumavarieswidelyduetoinfluences direct blows to the flank, right or left upper quadrants respectively of society, welfare and firearms legislation. In blunt trauma involving forceful abdominal compression Unfortunately, it is often impossible to tell from the appearance and/or deceleration (e. Assessment of the abdomen Theabdomenextendsfromthenipplestothegroincreaseanteriorly (Figure 15. Any blunt or penetrating injury within or through this region should raise the suspicion of abdominal injury. It is essential to perform a thorough primary survey and not be distracted by any obvious injury. Upper abdominal injuries intoxicated patient where a systolic of 60–70 mmHg should be the can cause a simple or tension pneumothorax or haemothorax, goal. Head injuries and injuries greater than 1 hour old are the only and cardiac tamponade may complicate penetrating cardiac injury exceptions to this rule and in these patients normotension is the in epigastric stab wounds. Analgesia Clinical examination should include a full examination of the Opiate analgesia should be used to control visceral pain following abdomen, flanks and back, particularly in cases of penetrating abdominal trauma. A rigid abdomen may reflect free intraperitoneal blood, contamination with bowel content or injury to the abdominal wall muscles, Evisceration particular in young patients with large abdominal muscles. Exposed ever, most patients with intraperitoneal haemorrhage will have bowel should be covered with saline soaked sterile pads or cling minimal pain. Prehospital ultrasound may be used to identify intrabdominal free fluid in the trauma patient which usually represents free blood. Prehospital management of abdominal injuries Resuscitation Suspected non-compressible abdominal haemorrhage resulting in hypotension should be managed by rapid evacuation to a surgical centre and permissive hypotension. Intravenous or intraosseus access should be obtained en route, and warmed intravenous fluid should be titrated using the patients level of consciousness (e. This will permit a lower blood pressure than selecting an arbitrary systolic target or presence/absence of a peripheral pulse. Trauma: Abdominal Injury 83 others requiring specialist surgical input, such as vascular control of major haemorrhage and treatment of complex visceral or solid organ injury. It is not possible to predict in the prehospital phase which abdominal injuries a patient has. For these reasons major centres with suitable facilities should be selected where possible. When faced with a hypotensive patient (particularly in penetrating trauma), call ahead as early as possible in the prehospital phase to request senior surgical presence and blood products in the emergency department. Tips from the field: • Clinical assessment of the abdomen has a low sensitivity and specificity. Intoxication, head injury or distracting injuries may make clinical assessment of the abdomen even more unreliable • The presence of a physiologically normal patient does not exclude Figure 15. Such objects are therefore best left in place • The majority of solid organ injuries can be managed until they can be removed in the operating theatre under control. Selectivenonoperative Solid organ injury is best treated by conservative management management of penetrating abdominal solid organ injuries. Some procedures are less resuscitation in patients with ruptured abdominal aortic aneurysm. Eur J technically challenging, such as splenectomy or liver packing, than Vasc Endovasc Surg 2006;31:339–344. Aetiology Pelvic fractures are associated with significant morbidity and mor- tality. They represent an application of significant force to the patient involved and are often found in association with mul- tisystem trauma. Falls from height, motor vehicle collisions and accidents related to horse riding are common mechanisms of injuries in major pelvic Figure 16. Low velocity falls in elderly people may cause significant life-threatening injury. Vertical shear injuries Significant shearing forces applied to the pelvis often lead to Injury classification unstable injuries. Damage to both anterior and posterior ligamen- Pelvic fractures can be classified according to the mechanism of tous complexes leads to vertical displacement of the hemipelvis injury and the effect this has on destabilizing the ‘ring’ of the pelvis. Often associated with lower long bone and spinal These injuries do occur in combination (combined mechanical injury. Anteroposterior injuries Lateral compression injuries Also known as ‘open book’ injuries. Significant force causes the This most common form of pelvic fracture is most often associated pelvis to open causing (potentially) massive damage to the venous with limb and head injuries. Fracture fragments may tear major plexus, bladder, urethra and occasionally the internal iliac artery vessels resulting in massive haemorrhage (Figure 16.

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