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Alternatively buy generic protonix 40 mg line gastritis diet äîì2, low-risk patients can undergo transesophageal echocardiography to exclude the presence of an atrial appendage thrombus prior to cardioversion purchase protonix on line definition de gastritis. Postcardioversion anticoagulation is still required for 4 weeks order protonix in united states online gastritis neck pain, because even though the rhythm returns to sinus order protonix toronto gastritis diet ÿíäćêń, the atria do not con- tract normally for some time. Pharmacologic cardioverting agents, though not as effective, include procainamide, sotalol, and amiodarone. The longer the patient is in fibrillation, the more likely the patient is to stay there (âatrial fibrillation begets atrial fibrillationâ) as a consequence of electrical remodeling of the heart. The major complication of warfarin therapy is bleeding as a consequence of excessive anticoagulation. If clinically significant bleeding is present, warfarin toxicity can be rapidly reversed with administration of vitamin K and fresh-frozen plasma to replace clotting factors and provide intravascular volume replacement. Because she has a history of acute rheumatic fever, her mitral stenosis almost certainly is a result of rheumatic heart disease. Rheumatic heart disease is a late sequela of acute rheumatic fever, arising many years after the original attack. The aortic valve may also develop stenosis, but usually in combination with the mitral valve. Almost all cases of mitral stenosis in adults are secondary to rheumatic heart disease, usually involving women. The physical signs of mitral stenosis are a loud S1 and an opening snap following S2. There is a low-pitched diastolic rumble after the opening snap, heard best at the apex with the bell of the stethoscope. Because of the stenotic valve, pres- sure in the left atrium is increased, leading to left atrial dilation and, ulti- mately, to pulmonary hypertension. Pulmonary hypertension can cause hemoptysis and signs of right-sided heart failure such as peripheral edema. Rate control with intravenous digoxin, beta-blockers, or calcium channel blockers is essential to relief of pulmonary symptoms. A portion of ventricular activation occurs over the accessory pathway, with the remaining occurring normally through the His-Purkinje system. If hemodynamically stable, the agent of choice is procainamide or ibutilide, to slow conduction and convert the rhythm to sinus. He reviews the charts of several patients with atrial fibrillation currently taking Coumadin. Which of the following patients is best suited to have anticoagulation discontinued? A 45-year-old man who has normal echocardiographic findings and no history of heart disease or hypertension, but a family his- tory of hyperlipidemia B. A 62-year-old man with mild chronic hypertension and dilated left atrium, but normal ejection fraction C. A 75-year-old woman who is in good health except for a prior stroke, from which she has recovered nearly all function D. The emergency room physician counsels the patient regarding cardioversion, but the patient declines. The early diastolic decrescendo murmur is typical of aortic regurgi- tation, holosystolic murmur at the apex that of mitral regurgitation, and late-peaking systolic murmur at the upper sternal border that of aortic stenosis. Conditions associated with a high risk for embolic stroke include a dilated left atrium, congestive heart failure, prior stroke, and the presence of a thrombus by echocardiogram. The man in answer A has âlone atrial fibrillationâ and has a low risk for stroke and thus would not benefit from anticoagulation. If the patient is stable, initial management is ventricu- lar rate control with an atrioventricular nodal-blocking agent, such as digoxin, beta-blockers, diltiazem, or verapamil. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. This page intentionally left blank Case 4 A 37-year-old executive returns to your office for follow-up of recurrent upper abdominal pain. He initially presented 6 weeks ago, complaining of an increase in frequency and severity of burning epigastric pain, which he has experienced occasionally for more than 2 years. Now the pain occurs three or four times per week, usually when he has an empty stomach, and it often awakens him at night. The pain usually is relieved within minutes by food or over-the-counter antacids but then recurs within 2 to 3 hours. He admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine and eating a lot of take-out foods. His medical history and review of systems were otherwise unremarkable, and, other than the antacids, he takes no medications. His physical examination was nor- mal, including stool guaiac that was negative for occult blood. His symp- toms resolved completely with the diet changes and daily use of the medication. Results of laboratory tests performed at his first visit show no anemia, but his serum Helicobacter pylori antibody test was positive. He does not take nonsteroidal anti-inflammatory drugs, which might cause ulcer formation, but he does have serologic evidence of H pylori infection. Recognize clinical features of duodenal ulcer, gastric ulcer, and features that increase concern for gastric cancer. He does not have âalarm symptoms,â such as weight loss, bleeding, or anemia, and his young age and chronicity of symptoms make gastric malignancy an unlikely cause for his symptoms. Dyspepsia can be intermittent or continuous, and it may or may not be related to meals. It produces a urease enzyme that splits urea, raising local pH and allowing it to survive in the acidic environment. Historical clues, knowledge of the epidemiology of diseases, and some simple laboratory assessments can help to separate benign from serious causes of pain. Gastroesophageal reflux typically produces âheartburn,â or burning epigastric or mid chest pain, usually occurring after meals and worsening with recumbency. Biliary colic caused by gallstones typically has acute onset of severe pain located in the right upper quadrant or epigastrium, usually is pre- cipitated by meals, especially fatty foods, lasts 30 to 60 minutes with sponta- neous resolution, and is more common in women. Irritable bowel syndrome is a diagnosis of exclusion but is suggested by chronic dysmotility symptoms, (bloating, cramping) often relieved with defecation, without weight loss or bleeding. The classic symptoms of duodenal ulcers are caused by the presence of acid without food or other buffers. Symptoms are typically produced after the stomach is emptied but food-stimulated acid production still persists, typically 2 to 5 hours after a meal. They may awaken patients at night, when circadian rhythms increase acid production. The pain is typically relieved within minutes by neutralization of acid by food or antacids (eg, calcium carbonate, aluminum-magnesium hydroxide).
Kleinâs first âpatientâ was her own daughter protonix 20mg gastritis diet quizzes, Melitta Schmideberg protonix 40mg lowest price gastritis diet management, who later became an analyst working with delinquent adolescents and who resented her own motherâs intrusions so early in life! Lieutenant General George Patton Jr found that it did not pay to slap a âpsychiatric casualtyâ and call him a âgoddamned cowardâ on August 3 1943 near Palermo protonix 40mg gastritis diet options, Sicily! At least 140 discount protonix 40 mg on line gastritis stress,000 institutionalised psychiatric patients died of mistreatment or starvation in Germany during the Nazi era. Albert Ellis (1913-2007), the American psychologist who developed rational emotive behaviour therapy in the mid-1950s, approached therapy with the armour of reason and persuasion in contrast to Beckâs use of theories that are tested by the patient in order to gauge their accuracy. Donald Meichenbaum of Ontario developed self-instructional training during the 1970s aimed at modulating impulse control problems through verbal self-regulation. Approximately 3,000 chronic patients, many of them intellectually handicapped, were sent their chained in Greek naval ships! Such viruses have been isolated from a western equatorial Africa subspecies of chimpanzee (Pan troglodytes troglodytes). The concept of a âslow virusâ as the cause of scrapie dates from 1954 and the Icelandic virologist BjĂ¶rn Sigurdsson (1913-59). Also, factors common to all psychotherapies may be independent of school of origin. Introduced by Dandy, an American, in 1918, it involved injecting a gas such as air into the cerebrospinal fluid spaces and then taking X-rays. Using this technique, Jakobi and Winkler (1927) described ventricular enlargement in schizophrenia. Purcell described the phenomenon of magnetic resonance (Nobel Prize, 1952) in 1946, two years before the first successful measurement of cerebral blood flow using nitrous oxide. The mouse genome was thoroughly mapped (Vincente & Kennedy, 1997) and then the human genome revealed many of its secrets. Cloning and somatic gene therapy, the introduction and expression of recombinant genes in somatic cells for the purpose of treating disease, have arrived. Lack of power to compel discharged treatment in the community to comply with treatment is a concern for modern psychiatry. A strong argument against an institutional 4052 basis form negative symptoms is the finding that these symptoms persist for at least nine years after discharge from hospital. A law of Northern Territory, Australia, allowing the terminally ill to take their own lives - using a computer-controlled lethal injection â was overturned in March, 1997; the Dutch authorities allow physician-assisted suicide, despite lack of statutory provision, and Belgian doctors failed to resist its introduction; and the American Supreme Court passed down decisions about physician-assisted suicide to the state legislatures, although the battle between the latter and the former continues. The Editor of the Irish Medical Journal, noting that out-patient clinics in the Republic of Ireland in 1996 were held at 251 locations with 233,512 attendances, described the situation as âa staggering burden on our psychiatric community servicesâ. Stroud: Tempus, 2004 (originally published as Mind Forgâd Manacles in 1987 by Athlone). A History of Caring for the Mentally Disordered at Bethlem Royal Hospital and the Maudsley. Medicine and Modernity: Public Health and Medical Care in Nineteenth- and Twentieth-Century Germany. Museums of Madness: the Social Organization of Insanity in Nineteenth Century England. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. Roine and Markku Kaste 5 Basic epidemiology of stroke and risk assessment 77 16 Acute therapies and interventions 230 Jaakko Tuomilehto, Markku MĂ€hĂ¶nen Richard OâBrien, Thorsten Steiner and Cinzia Sarti and Kennedy R. Lees 6 Common risk factors and prevention 89 17 Management of acute ischemic stroke Michael Brainin, Yvonne Teuschl and its complications 243 and Karl Matz Natan M. Bornstein and Eitan Auriel v Contents 18 Infections in stroke 258 20 Neurorehabilitation 283 Achim Kaasch and Harald Seifert Sylvan J. Albert and JĂŒrg Kesselring 19 Secondary prevention 272 Hans-Christoph Diener and Greg W. Albers Index 307 vi Preface This book is designed to improve the teaching and to interfere with the individual character of each learning of stroke medicine in postgraduate educa- chapter, leaving only duplicate presentations when tional programs. It is targeted at âbeginning special- they were handled from different topological or didac- istsâ, either medical students with a deeper interest tic aspects, e. Therefore the text contains what is gered by the âEuropean Master in Stroke Medicine considered essential for this readership but, in addi- Programmeâ held at Danube University in Austria. Thus, we hope to satisfy the needs of students tried to keep the clinical aspects to the fore, giving and young doctors from many different countries, relative weight to those chapters that cover clinically both within and outside Europe. The book benefits from the experi- expert help in summarizing the chaptersâ contents. In places this leads to some differences of opinion in the approach to particular Michael Brainin patients or conditions; as Editors we have tried not Wolf-Dieter Heiss vii Contributors Gregory W. All these vascular disorders can cause in the vessels supplying or draining the brain. The basic pathological lesion is the atheroma- stenosis or occlusion at the site of vascular changes, tous plaque, and the most commonly affected sites are disruption of blood supply and consecutive infarcts the aorta, the coronary arteries, the carotid artery at can also be produced by emboli arising from vascular its bifurcation, and the basilar artery. Arteriosclerosis, lesions situated proximally to otherwise healthy a more generic term describing hardening and branches located more distal in the arterial tree or thickening of the arteries, includes as an additional from a source located in the heart. At the site of type MĂ¶nkebergâs sclerosis and is characterized by occlusion, the opportunity exists for thrombus to calcification in the tunica media and arteriolosclerosis develop in anterograde fashion throughout the length with proliferative and hyaline changes affecting the of the vessel, but this event seems to occur only rarely. Atherosclerosis starts at a young age, and Changes in large arteries supplying the brain, lesions accumulate and grow throughout life and including the aorta, are mainly caused by athero- become symptomatic and clinically evident when sclerosis. Those changes occur in childhood and adoles- tis, SjĂ¶grenâs syndrome, or Sneddon and Behcetâs cence and do not necessarily correspond to the future disease. Fatty streaks are focal brain the etiology and pathogenesis are still unclear, areas of intracellular lipid collection in both macro- e. Various concepts but these disorders are characterized by typical have been proposed to explain the progression of such locations of the vascular changes. This inflam- plaques thrombosis forming on the disrupted lesion mation develops concurrently with the accumulation further narrows the vessel lumen and can lead to occlu- of minimally oxidized low-density lipoproteins [4, 5], sion or be the origin of emboli. The complex interactions of these many factors are discussed in the Thromboembolism specialist literature [4â6].
General appearance: A great deal of information is gathered by observa- tion order 40 mg protonix free shipping gastritis fatigue, as one notes the patientâs body habitus best buy for protonix gastritis medication list, state of grooming generic protonix 20mg free shipping diet by gastritis, nutri- tional status 40mg protonix with amex gastritis chronic erosive, level of anxiety (or perhaps inappropriate indifference), degree of pain or comfort, mental status, speech patterns, and use of lan- guage. Blood pressure can sometimes be different in the two arms; initially, it should be measured in both arms. In patients with suspected hypovolemia, pulse and blood pressure should be taken in lying and standing positions to look for orthostatic hypoten- sion. It is quite useful to take the vital signs oneself, rather than relying upon numbers gathered by ancillary personnel using automated equip- ment, because important decisions regarding patient care are often made using the vital signs as an important determining factor. Head and neck examination: Facial or periorbital edema and pupillary responses should be noted. Funduscopic examination provides a way to visu- alize the effects of diseases such as diabetes on the microvasculature; papilledema can signify increased intracranial pressure. The thyroid should be palpated for a goiter or nodule, and carotid arteries auscultated for bruits. Breast examination: Inspect for symmetry, skin or nipple retraction with the patientâs hands on her hips (to accentuate the pectoral muscles), and also with arms raised. With the patient sitting and supine, the breasts should then be palpated systematically to assess for masses. The nipple should be assessed for discharge and the axillary and supraclavicular regions should be examined for adenopathy. Murmurs should be classified according to intensity, duration, timing in the cardiac cycle, and changes with various maneu- vers. Systolic murmurs are very common and often physiologic; diastolic murmurs are uncommon and usually pathologic. Pulmonary examination: The lung fields should be examined systemati- cally and thoroughly. Percussion of the lung fields may be helpful in identifying the hyperresonance of tension pneumothorax, or the dullness of consolidated pneumonia or a pleural effusion. Abdominal examination: The abdomen should be inspected for scars, dis- tension, or discoloration (such as the Grey Turner sign of discoloration at the flank areas indicating intra-abdominal or retroperitoneal hemor- rhage). Auscultation of bowel sounds to identify normal versus high- pitched and hyperactive versus hypoactive. Percussion of the abdomen can be utilized to assess the size of the liver and spleen, and to detect ascites by noting shifting dullness. Careful palpation should begin ini- tially away from the area of pain, involving one hand on top of the other, to assess for masses, tenderness, and peritoneal signs. Tenderness should be recorded on a scale (eg, 1 to 4 where 4 is the most severe pain). Back and spine examination: The back should be assessed for symmetry, tenderness, and masses. The flank regions are particularly important to assess for pain on percussion, which might indicate renal disease. Females: The pelvic examination should include an inspection of the external genitalia, and with the speculum, evaluation of the vagina and cervix. A bimanual examination to assess the size, shape, and tenderness of the uterus and adnexa is important. Palpation for hernias in the inguinal region with the patient coughing to increase intra- abdominal pressure is useful. Rectal examination: A digital rectal examination is generally performed for those individuals with possible colorectal disease, or gastrointestinal bleed- ing. Extremities: An examination for joint effusions, tenderness, edema, and cyanosis may be helpful. Clubbing of the nails might indicate pulmonary diseases such as lung cancer or chronic cyanotic heart disease. Neurological examination: Patients who present with neurological com- plaints usually require a thorough assessment, including the mental status, cranial nerves, motor strength, sensation, and reflexes. The skin should be carefully examined for evidence of pigmented lesions (melanoma), cyanosis, or rashes that may indicate systemic disease (malar rash of systemic lupus erythematosus). Urinalysis is often referred to as a âliquid renal biopsy,â because the presence of cells, casts, protein, or bacteria provides clues about under- lying glomerular or tubular diseases. Gram stain and culture of urine, sputum, and cerebrospinal fluid, as well as blood cultures, are frequently useful to isolate the cause of infection. Chest radiography is extremely useful in assessing cardiac size and con- tour, chamber enlargement, pulmonary vasculature and infiltrates, and the presence of pleural effusions. Ultrasonographic examination is useful for identifying fluid-solid inter- faces, and for characterizing masses as cystic, solid, or complex. It is also very helpful in evaluating the biliary tree, kidney size, and evidence of Clinical Pearl â€ Ultrasonography is helpful in evaluating the biliary tree,looking for ureteral obstruction,and evaluating vascular structures,but has limited utility in obese patients. Ultrasonography is noninvasive and has no radiation risk, but cannot be used to penetrate through bone or air, and is less useful in obese patients. Echocardiography: Uses ultrasonography to delineate the car- diac size, function, ejection fraction, and presence of valvular dysfunction. Angiography: Radiopaque dye is injected into various vessels and radiographs or fluoroscopic images are used to determine the vascu- lar occlusion, cardiac function, or valvular integrity. Nuclear medicine imaging of the heart can be added to increase the sensitivity and specificity of the test. Individuals who cannot run on the treadmill (such as those with severe arthritis), may be given medications such as adenosine or dobutamine to âstressâ the heart. The first diagnostic concern of most patients and physicians regarding chest pain is angina pectoris, that is, the pain of myocardial ischemia caused by coronary insufficiency. Distinguishing angina pectoris from other causes of chest pain relies upon two important factors: the clinical history, and an understanding of how to use objective testing. In making the diagnosis of angina pectoris, the clinician must establish whether the pain satisfies the three criteria for typical anginal pain: (1) retrosternal in location, (2) precipitated by exertion, and (3) relieved within minutes by rest or nitroglycerin. Then, the clinician considers other factors, such as patient age and other risk factors, to determine a pretest probability for angina pectoris. After a pretest probability is estimated by applying some combination of sta- tistical data, epidemiology of the disease, and clinical experience, the next deci- sion is whether and how to use an objective test. For example, a 21-year-old woman with chest pain that is not exertional and not relieved by rest or nitroglycerin has a very low pretest probability of coronary artery disease, and any positive results on a cardiac stress test are very likely to be false positive. Any test result is unlikely to change her management; thus, the test should not be obtained. Similarly, a 69-year-old diabetic smoker with a recent coronary angioplasty who now has recurrent episodes of typical angina has a very high pretest probability that the pain is a result of myocardial ischemia. One could argue that a negative cardiac stress test is likely to be a falsely negative, and that the clinician should proceed directly to a coronary angiography to assess for a repeat angioplasty. Diagnostic tests, therefore, are usually most useful for those patients in the midranges of pretest probabilities in whom a positive or negative test will move the clinician past some decision threshold. Patients are monitored on an electrocardiogram, while they perform graded exer- cise on a treadmill. If one knows the sensitivity and specificity of the test used, one can calculate the likelihood ratio of the positive test as sensitivity/(1â specificity). Posttest probability is calculated by multiplying the positive likelihood ratio by the pretest probability, or plot the probabilities using a nomogram (see Figure Iâ1).
The treatment of addiction involving opioids presents one of the most glaring examples of the The reason I am not interested [in prescribing underutilization of clinically-effective and cost- buprenorphine] is I see this as an opportunity for effective pharmaceutical treatments for drug users who are by class the most lying purchase protonix 40 mg without prescription gastritis emocional, 91 addiction buy protonix online from canada gastritis diet 444. They need treatment for addiction involving opioids that buy discount protonix 20mg online gastritis jelentese, hard-based purchase protonix 40 mg with mastercard gastritis diet òćëćïđîăđàììà, no-nonsense treatment programs. I 90 despite a rich body of evidence demonstrating its canât stand their manipulative behavior. The majority (86 percent) of addiction counselors report not being aware of the effectiveness of The fact that buprenorphine can be prescribed in 95 buprenorphine. Addiction professionals buprenorphine] than we expected, especially anticipated the medicationâs potential to help 96 among primary care physicians. Director, Clinical and Health Services Research and Education Division of Alcohol Physiciansâ biases against patients with and Drug Abuse, McLean Hospital addiction may contribute to the limited adoption 98 of pharmaceutical treatments as well. Survey results from a random sample of internal -207- Nutrition and Exercise Are Not Integrated solely via support groups composed of those into Addiction Treatment. One small study found that 56 conditions and other personal characteristics and percent of dietitians and nutrition program life circumstances that might affect treatment managers working in addiction treatment outcome, most health professionals and facilities reported that their facilities offered addiction treatment programs follow a one-size- nutrition-related addiction education in group fits-all approach to treatment. Fifty-six percent of respondents reported Disease Severity Rarely is Assessed and offering nutrition-related addiction education in Interventions Rarely are Tailored to Stage individual settings to an average of 18 percent of and Severity of Disease. Assessment of disease considerable evidence--although largely severity is an essential part of addiction anecdotal--of the benefits of mutual support 109 treatment as well. Yet, the extent to which treatment âĄ 106 follow evidence-based clinical treatment. Such support, however, is quite different than Having patients pass through a rigid, time- Â§ 107 treatment for a medical condition. Few limited treatment program that assumes would argue that any other disease be treated uniformity in disease symptoms and severity simply burdens patients with unnecessarily * extensive interventions or with interventions that See Chapter V. Yet the standard There are some exceptions where, depending on the severity of disease symptoms and the patientâs health treatment for addiction is non-intensive 113 status and degree of social support, certain patients outpatient treatment, often without adequate are able to manage their addiction with support professional follow-up care and disease services only or no interventions at all. Even residential treatment should be noted that Twelve-Step Facilitation, typically is limited to a 28-day stay in a program discussed in Chapter V, is a formalization and despite little evidence that the condition remits professionalization of the 12-step mutual support 114 after such a brief period of time. Given this model and has been deemed an evidence-based standard approach to treatment that focuses treatment for addiction. Only five included a comprehensive Abuse and Alcoholism medical assessment; in fact, only three even had (currently, Associate Professor of Psychiatry, a full-time doctor on the premises. And University of Minnesota) although they each viewed his condition as a chronic disease requiring effective aftercare and long term management, none of them had an Interventions Do Not Adequately Address effective recommendation for this, nor any Co-occurring Conditions. In a letter to me practice, it is recommended that health during one of his stays in a residential program, professionals assess the presence of co-occurring he offered the insight that much of his previous rounds of treatment had addressed his addiction conditions in order to develop an effective in isolation--as if it were unrelated to any treatment plan and tailor treatment 116 underlying emotional problems. Although such assessments are weeks of his life, Brian was suffering from critical in addiction treatment given the very severe depression. On the day before he died, high rate of co-occurring conditions in people his aftercare program made the decision, with addiction, treatment programs frequently without consulting Brianâs therapist, or his do not address co-occurring health conditions or parents, to terminate their relationship with him. Implementing a one-size-fits-all approach to --Gary Mendell, father treatment based solely on a clinical diagnosis Lost his son Brian, age 25, without consideration of co-occurring health to addiction and suicide conditions often amounts to a waste of time and resources. Generally psychiatrists are less likely than family physicians to inquire about A recent study of patients in residential smoking, offer advice on quitting or assess treatment for addiction who had co-occurring 122 patientsâ willingness to quit. Yet, because mental health conditions underscores the individuals with severe mental illness interact importance of tailoring treatment to the needs of with psychiatrists to a greater extent than with the patient population. In this study, those with primary care physicians (who typically are the co-occurring mental health conditions reported main referral source or provider of smoking less satisfaction with treatment, saw fewer cessation interventions), patients in mental -209- health settings who smoke may be even less Patients with addiction, regardless of the stage likely to receive the smoking cessation services and severity of their disease, typically receive a 123 they need. Psychiatrists may eschew smoking diagnosis followed by a swift course of cessation interventions because they believe treatment administered by individuals without âpatients have more immediate problems to any medical training and then minimal to no 133 address;â some medical and other health follow-up care. In contrast to other chronic professionals also may be reluctant to encourage diseases, positive results from a short-term smoking cessation because they feel it âgives intervention or treatment for addiction are patients with psychiatric illnesses comfort while expected to endure indefinitely and relapse 124 dealing with their mental illness symptoms. Evidence of the acute care approach to addiction treatment is that current Medicare and Medicaid Interventions Rarely are Tailored to Patient regulations indicate that hospital readmissions Characteristics that Might Affect Treatment for patients with addiction involving alcohol are Outcomes. Not taking into account a patientâs not to be treated as extensions of the original age, gender, race/ethnicity, socioeconomic status treatment but rather as a new admission to treat or system of personal supports in designing a the same condition. Readmissions can be seen treatment intervention can compromise as evidence that treatment is not working and otherwise effective treatment plans. While the baseline would improve the patientâs condition, or level of addiction-related services offered to the documents why the initial treatment was 135 general population is inadequate, the deficiency insufficient. Given that addiction often is a in tailored services offered to populations with chronic disease and that relapse is possible, 127 special treatment needs is even more glaring. For many individuals, addiction manifests as a chronic disease, requiring disease and symptom 128 management over the long term. In recent years, there has been growing recognition of the importance of comprehensive disease management in the treatment of chronic health conditions for which there is no known cure, where relapse episodes are considered an expected part of the disease course and where long-term symptom management is considered routine care. While this approach increasingly has been adopted for diseases such as 129 130 131 diabetes, hypertension and asthma, addiction treatment largely remains stuck in the 132 acute-care model. While most of these approaches have been discredited with time, some have proven to be prescient in their foreshadowing of current treatment approaches, both those that are evidence based and those that continue to profit from claims about being able to treat or even cure addiction in manners that largely are not based on scientific evidence. Benjamin Rush, the âfather of American psychiatry,â was the first American doctor to say 136 137 th that âhabitual drunkenness should be regarded not as a bad habit but as a diseaseâ that should be treated. In the late 19 century, medically-based addiction treatment mostly involved trying to cure individuals of their addiction, often with the use 138 of other addictive substances. By 1910, private sanitariums in the United States offered specialized treatment for addicted individuals--but only for those who could afford the expense. Similar to today, many of the âtreatment expertsâ opening facilities were savvy businessmen or enterprising physicians, including Harvey Kellogg (later of cereal fame) and Dr. Between 1892 and 139 1893, almost 15,000 people with addiction were treated at the famous, yet controversial Keeley Institutes. Keeleyâs treatment for addiction involved bichloride of gold remedies, a substance purportedly containing gold that would cure addiction involving alcohol and opioids. Keeley in 1900, the popularity and ultimately, the existence of 140 his institutes waned. Although Keeleyâs treatments were later discredited, his position that addiction was decidedly a disease rather than a religious or moral failing was ahead of its time. His use of âshot treatmentsâ or hypodermic treatments that induced vomiting was a precursor to later aversion therapies and his introduction of clubs for addicted individuals to receive social support to maintain sobriety was a precursor to the mutual support programs that remain prominent today. His focus on helping people 141 quit smoking in the 1920s was prescient in its characterization of nicotine as a harmful and addicting drug. Addiction treatment tactics that are based more on the personal charisma of the founders, catchy phrases and simplistic approaches than on the science of what works in addiction continue to proliferate and show no sign of waning. A simple Google search produces an abundance of ârehabilitationâ approaches and facilities with slogans such as: Learn how to heal 142 the underlying causes of dependency--and be free of addiction forever! A recent study examining treatments that a panel * of experts believes qualifies as quackery in addiction treatment found such treatments as electrical stimulation of the head, past-life therapy, electric shock therapy, psychedelic medication and neuro-linguistic programming to be âcertainly 143 discredited.
Effective communicative competence on the part of the medical professional would generic protonix 20mg line gastritis kefir, first buy protonix 20 mg fast delivery gastritis diet ôàöćáîîê, 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 buy protonix without a prescription gastritis symptoms lower abdominal pain. This is the productive element of the communicative competence cheap protonix 40mg line gastritis symptoms back, 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 patientâs 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. Compounding the difficulty of this task is the quantity and di- versity of the variants that occur in clinic, as briefly alluded to in the description of the variants. Second, due to the fact that many variants are region specific and informal in nature, though it would be useful to learn them in order to understand the patient, they are not as readily useful in terms of productive language. Many times, the patientâs country of origin is unknown and, additionally, it is nearly impossible to know which terms are familiar to that particular patient. Inserting dialect variants with the hope of making the patient feel more comfortable and more likely to understand the medical professional without knowing more about them could actually result in the opposite effect â a distancing of the patient or even an offense. Finally, given that some variants are due to pronunciation differences or interferences from English, the 4 For more information on factors which give rise to higher variant use among patients and which inhibit the patientâs participation in the resolution of misunderstandings, please see Bennink (2014). This represents a linguistic understanding that is far too demanding for most physicians who are already setting aside part of their all too scarce time to learn Spanish. Lastly, even if the medical professional had the desire to learn some of the dialect variants or turn to reference materials such as dic- tionaries when they do not understand a term or phrase, they may be surprised to discover a great absence of variants in both of these re- sources. During the aforementioned study carried out by Bennink in 2013, there was also an analysis of the inclusion of dialect variants in Spanish for medical professionals courses and manuals used within the studied region as well as in some dictionaries used as reference. Finally, in terms of the dictionaries, the analysis of the Diccionario de la Lengua EspaĂ±ola from the Real Academia EspaĂ±ola (2001), the Diccionario del EspaĂ±ol Usual de MĂ©xico (Fernando Lara 2000), the Southwestern Medical (Artschwager Kay 2001), and a later comparison with the Diccionario de Americanismos (AsociaciĂłn de Academias de la Lengua EspaĂ±ola 2010) confirmed that each one is missing some of the variants found to be frequent in the medical setting. Conclusion As has been illustrated, dialect variants in cross-lingual medical com- munication are not only prevalent but also, when unfamiliar to the medical professional, can potentially have a negative impact on care. However, when seeking to integrate them into the communicative competence of the healthcare professionals, various challenges are confronted, including the patientâs communication skills, the quantity and diversity of variants and the lack of educational and resource materials that incorporate dialectal terms. Though the intention in this chapter is not to give an answer for each of these challenges, it should be mentioned that Bennink and those at the Universidad de Oviedo are currently conducting research that aspires to address this need. The final goal of this repertoire will be its use as a resource in clinic and as the basis for the creation of material for Spanish for medical professionals courses. Searching for understanding in the medical consultation: Language accommodation and the use of dialect variants among Latino patients in Murawska, Magdalena / Szczepaniak-Kozak, Anna / Wasikiewicz-Firlej, Emilia (eds) Discourse in Co(n)text â The Many Faces of Specialized Discourse. Introduction Although medical evidence has always been critical in legal and admi- nistrative proceedings, proper medical expert witnesses have only ap- peared in criminal courts relatively recently. As Stygall (2001: 331) explains, â[m]any observers of the rise of the professions tend to treat expertise as a modern phenomenon, associated with the rise of the th professions and the academic disciplines in the 19 centuryâ. Since then, as professionals with a specialized knowledge, doctors and physicians have had an obligation to assist and provide their expertise in the administration of justice. Through their education and experience, expert witnesses can provide the court with an assessment or opinion within their area of competence, which is not considered to be the domain of other professionals in court, such as the lawyers and the judge. The aim of this study is to investigate medical discourse in historical criminal trials in order to ascertain whether specific discursive practices were employed. The offence considered is infanticide and the narratives, cross-examinations and re-examinations involving doctors, physicians, pathologists, practitioners and âmasters in surgeryâ are investigated both quantitatively and qualitatively, providing examples of medical testimony which give a specialist and authoritative account of the physical examination of both victims and murderers. It has been observed that specific discursive practices account for the search for âbalance between credibility and comprehensibilityâ (Cotterill 2003: 196) in a context where the discourse is to be considered both professional/lay and inter-professional (Linell 1998: 143). Medical experts find themselves simultaneously engaged in these two types of discourse: their testimonies are in fact for the benefit of a lay jury and lay people in general who lack understanding of and experience with both the legal and the medical genres and jargon. Additionally, the interactional dyad lawyer/medical expert can be considered to be an inter-professional type of discourse inasmuch as two competing modes of reasoning represent profession-specific approaches to the particular case in hand. Nowadays, expert witnesses occupy a unique position in court trials: unlike lay witnesses, they have more privileges and prerogatives, such as the right to give lengthier answers, to contradict their interlocutors, as well as to draw conclusions and express opinions on the strength of their experience and expertise. Outside the courtroom setting, they enjoy the same professional status and social standing of lawyers and judges, thanks to their competence and domain knowledge. However, since the witness box is a place outside their professional context, the experts are subject to the rule and role constraints which characterize the courtroom trial (2003: 168). As Linell (1998: 144) points out, this is because human beings wander between situations, just as discourse and discursive content travel across situations. The present chapter starts from an investigation of the position of expert witnesses in the historical courtroom, since it seems that in the past they did not enjoy the same social status and professional standing as their present-day colleagues. Additionally, as one might expect when dealing with historical data, especially spoken texts such as trial proceedings and witness testimonies, other questions such as The Old-Bailey Proceedings: Medical Discourse in Criminal Cases 233 source validity and accuracy may arise and these too merit close scrutiny. Materials and methodology The present study has drawn upon various studies which have dealt with courtroom discourse from wide-ranging, though often complementary, perspectives. A certain number of investigations looked at the socio-pragmatic aspects of courtroom discourse and are sometimes based on the description and exploration of actual courtroom proceedings, such as those in Atkinson and Drew (1979), Cotterill (2003), and Heffer (2005). Among these, some are conversationally-oriented studies looking at language in interaction in various institutional contexts and focus on the interactional dynamics of the courtroom, such as turn-taking and the sequential organization of discourse, for instance Heritage (2004), and Thornborrow (2002). Furthermore, the particular role of expert witnesses in the court- room and the fundamental matters of identity, credibility, power and social relationships therein, together with the ways these are negotiated through discourse, are discussed in depth by Chaemsaithong (2012), Maley (2000), and Stygall (2001). For the purpose of this chapter, useful insights were also gained from works about historical courtroom discourse such as those by Archer (2005) Chaemsaithong, (2011), Kryk-Kastovsky (2000; 2006), and those on historical data based on spoken interaction, e. The data for the present investigation are drawn from the Old Bailey Proceedings website which contains the proceedings of English criminal trial sessions from 1674 to 1913, after which publication came to a sudden halt. The earlier corpus built for this purpose entailed a first stage search for transcripts in the website containing 234 Michela Giordano the keywords doctor, surgeon, physician, practitioner, pathologist in the texts, since it was presumed that their presence in the text might demonstrate the actual involvement of such professionals and their practice in the unfolding of the trial. In the second stage, the search was narrowed down to trial accounts from January 1900 to December 1913, the last year in which the proceedings were published. Table 2 only contains the fourteen trials in which medical examinations were discussed and shows the total number of words in each transcript, the number of medical experts who testified in each trial and the number of words in the medical examinations. Despite the relatively small amount of data analysed, the results obtained do substantiate the conviction that the testimonies examined are representative of medical discourse in the th legal context in the early 20 century. It is worth noting that the transcripts in the website do not generally report the lawyersâ or judgesâ questions, which were often omitted or abridged in the Proceedings. It is equally important to reiterate that the discourse in exami- nations was organized into a series of question and answer pairs, where both the turn order and the type of turn allocated to each party are fixed and pre-determined, as can be expected when dealing with a type of institutional discourse where specific forms of interaction are embedded in specific workplace contexts (Atkinson/Drew 1979; Thornborrow 2002; Heritage 2004).
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