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When this occurs order 250mg panmycin with amex, give the total number of pages of the part you wish to cite purchase 500mg panmycin overnight delivery, placed in square brackets, such as [5 p. Part in a book with unusual pagination or no pagination Language of the Part of a Book (required) General Rules for Language Give the language of publication if not English Capitalize the language name Follow the language name with a period Specific Rules for Language Titles for parts in more than one language Examples for Language 27. Parts of non-English books 202 Citing Medicine Examples of Citations to Parts of Books 1. Overview figure, Comparison (transverse sections) of a muscular artery, large vein, and the three types of capillaries; p. Community health and social services: an introduction for medical undergraduates, health visitors, social workers and midwives. Appendix in a book with name implied University of Cape Town, Medical School, Department of Pharmacology. 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It is only insofar as one is able to understand (thus generic panmycin 500mg amex, the necessity to study the Oath) how the Oath might have spoken to its own culture that one will be able to see how relevant it is for his or her own buy 250mg panmycin mastercard. This begs the question as to know whether everyone will recognize the moral values and obligations described in the Oath as relevant for contem- porary medicine. As I have emphasized, scholars such as Miles who regard the Hippo- cratic Oath simply as symbolic discount the full force of its power as a doc- ument to direct professional conduct. Thus although Greek medicine recognized and emphasized the idea of a guild/profession, it appears that it does not correspond to today s model of medical practice. Gone too are the simple certainties of an ethic based entirely on what the doctor thinks is good for the patient, and with it also any acquaintance with Hippocratic morality outside the Oath and a few phrases such as primum non nocere... Professors of medical history are giving way to medical ethicists as the keepers of the medical con- science, or are themselves turning to history of ethics as a way to ensure the relevance of their own discipline in a modern medical school. The reasons are multiple and they deserve a more careful examination than what I will be able to accomplish in this article. However, it is crucial to locate the development of medicine in its proper context, par- ticularly how American medicine went from the status of guild power between 1930 and 1965 to its decline in power from 1970 to 1990 (Krause, 1996). The turning point, Krause argued, is the introduction of the Medicare- Medicaid Act (1965 1966) during the Kennedy and Johnson administrations (1961 1969). These two programs forced the federal government, through Congress, to seek to control the increasing costs of health care. First, the medical profession could not maintain the independent professional and moral identity necessary to sustain a particular tradition, that is, the Hippocratic tradition. The reflection on the moral dimension of medical practice came to occur mostly outside the medical profession as bioethics gained respectability as an academic field. Cost containment appeared suddenly as a moral obligation imposed on the physician. This means that the physicians are no longer exclusively committed to their patients but also dependent on and controlled by the social institutions that structure health care, in particular its economic aspects. These two factors contributed to the deprofessionalisation and the transformation of medicine into a vast industry, in which physicians lost their authority as professionals and became dependent on managed care 16 organizations for their economic survival. Current Efforts to Reconsider Medical Professionalism Some critics see in this transformation of medicine (Miles included, see for instance p. In response to these concerns, various efforts to reconsider and examine the concept of medical professionalism have taken place. Interestingly and in rela- tion to Miles analysis of the Hippocratic Oath, Jay Johansen wonders whether such a charter on medical professionalism will replace the Hippo- cratic Oath (Johansen, 2002). It is too early to say at this stage, but, as occurred when the Hippocratic Oath was formulated, the charter s publica- tion is an attem pt to (re)affirm som e of the fundam ental principles neces- sary for the practice of medicine. This document (The Charter on Medical Professionalism ) calls for a renewed sense of professionalism and responds to physicians frustrated by how health care is provided in society, which, it is argued, threaten the 17 very nature and values of medical professionalism. As is the case for the Hippocratic tradition, it is difficult to assess to what extent this charter built on the moral traditions of physicians has cur- rent moral significance for the medical profession. One of the main prob- lems is that the terminology of the document appears too vague and imprecise to count as a medical morality for the medical profession. In light of the plurality of moral visions shaping the contemporary culture, the three fundamental principles of the charter (prim acy of patient welfare, patient autonom y, and social justice) are subject to many interpretations and conclusions. W hat is clear is that the Hippocratic tradition and its concept of medical guild and the concept of medical professionalism (as defined by the Charter on Medical Professionalism ) cannot secure a coherent medical morality. As David Thomasma asserts, a moral philosophy of medicine must be linked to a philosophy of medicine in order to provide the foundation of the medical profession (Thomasma, 1997, p. Rethinking Medical Professionalism The question is whether the values and norms necessary to sustain the prac- tice of medicine as a profession lie outside medicine or whether medicine, by its very nature, involves certain inherent sets of moral and professional commitments. The dependence of physicians on social institutions for the delivery of health care has created a new paradigm in which physicians have a social obligation to respect cost containment policies, which sometimes affect the welfare of the patients. Furthermore, the rise in power of bioethics and of bioethicists as moral expects reflects the crisis in the moral identity of the medical pro- fession, while creating suspicion in society, due to the uncertainty of the 18 moral character of medicine. In short, medicine has been deprofessionalized and transformed according to a new set of socio-economic factors. The tendency of current bioethical reflection to move from ethical reflection to legal and economic concerns (bio-politics) has proven insufficient to sustain the moral identity of the medical profession. As we have seen, it is impossible to return to the values sustained by the Hippocratic tradition. Therefore, it is necessary to rethink medical profes- sionalism within our particular context which in turn requires recognizing the profound transformation of the medical profession in the last few decades while acknowledging that such reconsideration is an inherently conserva- tive undertaking in that it is bound to the moral traditions of physicians The Hippocratic Oath and Contem porary Medicine 119 (Miles, 2002, p. As many scholars point out, a reconsideration of medical professionalism does not necessarily imply a return to old under- standings of medical practice (paternalism, physician-patient relationship, etc. David Thomasma suggests a call to move beyond contemporary bioet- hics to a moral philosophy of medicine (Thomasma, 1997, p.

References Tis potentially results in conformal target cover- age also for complex motion patterns that are not [1] C buy discount panmycin 250mg line. Te rescanning also increases the robustness of the method generic panmycin 500 mg fast delivery, as other variable errors are also averaged. Similar to rescanning, fractionation also leads to averaging of random dose errors, though inhomo- geneous fraction doses have to be accepted. Tese studies show that densely Biologically-optimised treatment plans are ofen ionising radiation induces a high fraction of clus- discussed in radiotherapy [1]. Tese efects are now the mainstream optimisation of the physical treatment plan for a research topic in particle radiobiology [2]. Clinical implementation of biologically-optimised plans is ofen hampered by the uncertainties in radiobiology. The inset shows a zoom of the distal penumbra, and the green line the increased range predicted by the biological model. Recent in vascular endothelial cell apoptosis is rapidly acti- vitro studies show indeed that carbon ions are more vated above 10 Gy per fraction [3], and that the efective than X-rays in killing stem cells from colon ceramide pathway orchestrated by acid sphingo- and pancreas cancers. Moreover, preliminary results myelinase is a major pathway for the apoptotic indicate an increased efectiveness of low-energy response. Indications of suppressed Radiotherapy is now clearly going towards hypo- angiogenesis with C-ions even at low doses suggest fractionation. Tis must be combined with systemic therapies to con- makes it possible to deliver single high doses to trol metastasis and increase survival. Combined tumours, sparing organs at risk and maintaining radio and chemotherapy protocols are already the dose to the normal parallel organs below the used in many cancers, such as glioblastoma multi- tolerance dose. Charged efects, defned as shrinkage of metastatic lesions particle therapy optimization, challenges far from the irradiation feld during radiotherapy and future directions. Engaging were assumed to play a role, this was hitherto not the vascular component of tumor response. Immunologically augmented cancer ease progression, requiring focal irradiation of treatment using modern radiotherapy. Changes in cellular and molecular parameters indicate a comprehen- sive immune reaction against the tumour. Tis is clear clinical evidence of immune-mediated abscopal efects, formerly observed in diferent animal models. Tey can be classifed Te unique property of such particles is that the according to several major tasks. Tis makes it possible to irradiate scatterers and collimators in the case of passive the target volume occupied by a tumour while beam delivery, one should simulate the radiation sparing surrounding healthy tissues (see Section 9 felds created due to interactions of beam particles Treatment planning ). Tis includes also the esti- biological dose distribution delivered to a patient is mation of the dose due to secondary neutrons and required for successful treatment. A key starting point in evaluating Second, the dose delivered to the patient can be the biological (i. Annual number of publications related to hadrontherapy, where respective Monte Carlo codes/tools were used. Estimated fully used now in the feld of hadrontherapy to from the Web of Science database (Thomson Reuters) in October 2013. Te main task of any model is to repro- duce the spatial distribution of energy deposition with sub-mm accuracy. Te strength of a Monte Carlo model is that not only 1D depth-dose curves can be reliably calculated, but also 3D dose distri- butions in tissues. In particular, the efect of lateral scattering can clearly be seen, which is much stronger for protons 38 than for 12C. In par- Secondary neutrons are produced by proton and ticular, such a validation may be necessary in the carbon-ion beams in materials of beam-line ele- presence of metallic implants in the patients body ments, collimators, range modulators and also in or for other quality assurance tasks (see Section 9). Te model was primary and secondary particle is calculated as a validated with experimental data for secondary collection of short steps during particle propagation neutrons produced by 200 A MeV 12C beam in a in the medium. However, the yields of relatively slow Some examples of modelling of nuclear reactions neutrons (with energy below 150 MeV) emitted at relevant to proton and carbon ion therapy are given large angles (20o and 30o) are overestimated by the below. Since Li, Be and B fragments along with 12C projectiles provide the main contribution to the total dose, the depth-dose distribution is also well reproduced. At the same time the yield of helium fragments is underestimated, presumably due to neglecting the cluster structure of 12C, which would otherwise enhance the emission of alpha par- ticles in the fragmentation of 12C. Since the momenta of photons from a single annihilation event are strongly correlated, a spatial distribution of positron-emitting nuclei can be reconstructed by tomographic methods and compared with the dis- tribution calculated for the planned dose. Fragments of target nuclei, 11C and 15O created by protons in tissues are evenly distrib- uted along the beam path with a sharp fall-of close to the Bragg peak. In contrast, the maximum of +- activity created by 12C nuclei is located close to the Bragg peak. Attenuation of 12C beam (black) and build-up of secondary fragments (from H to B, see the legend) in nuclear reactions induced by 400A MeV carbon nuclei in water.

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Prolonged use of neuromuscular-blocking drugs combined with corticosteroids can cause severe myopathy that requires rehabilitation measures discount panmycin 250mg with visa. If the patient is a corticosteroid-dependent asthmatic patient currently on a maintenance dose of prednisone discount panmycin 500 mg with mastercard, increase the dose of prednisone instead of relying on increased use of bronchodilators or inhaled corticosteroids to ensure complete control of asthma. If the patient is dependent on inhaled corticosteroids, a short course (4 to 5 days) of prednisone (25 to 40 mg/day) before surgery is recommended to maximize pulmonary function. The main need for corticosteroids, however, is prevention of intraoperative or postoperative asthma rather than adrenal crisis. Hydrocortisone, 100 mg intravenously, should be started before surgery and continued every 8 hours until the patient can tolerate oral or inhaled medications ( 296). The doses of prednisone and hydrocortisone needed to control asthma do not increase postoperative complications, such as wound infection or dehiscence ( 296). In patients with asthma, optimal respiratory status should be achieved before surgery occurs. Aerosol bronchodilators, deep-breathing exercises, adequate hydration, and gentle coughing should be instituted to avoid accumulation of secretions and atelectasis. Use of epidural or spinal anesthesia is not necessarily safer than general anesthesia ( 297). These complications are thought to result from the rupture of overdistended peripheral alveoli. The escaping air then follows and dissects through bronchovascular sheaths of the lung parenchyma. When severe tension symptoms occur, insertion of a chest tube under a water seal for pneumothorax may be needed. Tracheostomy may be required for severe tension complications of pneumomediastinum. A common feature of these conditions is chest pain; this is not expected with uncomplicated asthma, and when present should suggest the possibility of the extravasation of air. On auscultation of the heart, a crunching sound synchronous with the heartbeat may be present with pneumomediastinum (Hamman sign). It is often reversible with bronchodilators and prednisone, given immediately to avoid the risk of bronchoscopy, or at least to prepare for this examination. When the atelectasis does not respond to the above treatment within a few days, bronchoscopy is indicated for both therapeutic and diagnostic reasons. Occasionally, children may develop atelectasis of other lobes or of an entire lung. Rib fracture and costochondritis may occur as a result of coughing during attacks of asthma. These conditions occur with irreversible destruction of lung tissue, whereas asthma is at least a partially to completely reversible inflammatory condition. The identification of bronchiectasis in a patient with asthma should raise the possibility of allergic bronchopulmonary aspergillosis, undiagnosed cystic fibrosis, or hypogammaglobulinemia. Hypoxemia from uncontrolled asthma has been associated with adverse effects on other organs, such as myocardial ischemia or infarction. Although this effect typically produces no clinical ramifications, in the exceptional patient, irreversible asthma occurs ( 141). Most of these patients do not have steroid-resistant asthma because they have more than 15% bronchodilator response to 2 weeks of daily prednisone. The increase in mortality rate from asthma that occurred in the 1980s in the United States appeared to stabilize by 1996 but has not declined ( 298). The use of repeated doses of b2-adrenergic aerosols has been suspected to be a contributing factor in some of these deaths but is unlikely to be a satisfactory explanation. Fatality rates are lower in the United States and Canada than in many countries, including as New Zealand and Australia. A 1980s surge in deaths in New Zealand and the availability of albuterol inhalers without prescription in that country has been considered possibly analogous to the earlier epidemics of the 1960s. Undue reliance on inhaled b 2-adrenergic agonists by patients and physicians may contribute to fatalities in patients with severe exacerbations of asthma because essential corticosteroid therapy is not being administered. In addition, excessive deaths associated with the potent b 2-adrenergic agonist fenoterol have been reported. This has led to the recommendation that, in persistent asthma, inhaled corticosteroids should be used in conjunction with b2-adrenergic agonists. The latter phenomenon may be exemplified by the use of inhaled corticosteroids, which will not substitute for oral corticosteroids acutely. Patients with underlying restrictive lung disease, because of reduction in functional residual capacity, tolerate status asthmaticus poorly as well because baseline lung function favors more easy collapsibility of bronchi. Some fatalities occur in the setting of no medical care or are associated with substance abuse even without a history of a previous nearly fatal attack (101). Specific curative therapy can be realized only when basic pathologic mechanisms are understood.