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A tense abdomen and the appearance of periumbilical (Cullen’s sign) and flank (Grey Turner’s sign) ecchymoses may indicate the degree of the inflammatory process cheap 25mg viagra super active otc impotence young men. Two prognostic scoring systems are used in acute pancreatitis – the Glasgow Scoring System discount viagra super active 50 mg without prescription erectile dysfunction drugs, and the Ranson Scoring System. Hypertriglyceridaemia is a known cause, especially if the serum triglycerides are over 1000mg/dL (11 mmol/L). Hypercalcaemia is also a possible cause, although the incidence of pancreatitis in patients with hyperparathyroidism is low. Acute biliary pancreatitis is due to impaction of a gallstone in the sphincter of Oddi. In severe pancreatitis due to biliary obstruction, endoscopic sphincterotomy with removal of the stone must be performed. The procedure may increase the risk of infection, and broad spectrum antibiotic cover must be given. A lot of vasoactive substances, activated enzymes and inflammatory mediators are generated locally, and this sets up a systemic inflammatory cascade which results in multi-organ dysfunction, which in turn makes the local necrosis worse. Supportive therapy: careful supportive therapy is of paramount importance and will prevent the development of multi-organ dysfunction. Adequacy of resuscitation must be judged by haemodynamic responses and urine output. Pleural effusions may occur (especially on the left), and may need drainage if they compromise respiration. If the patient is haemodynamically unstable, continuous renal replacement therapy will be the preferred modality. Severe abdominal distension due to paralytic ileus resulting in significant intra-abdominal hypertension may take place. Decompression of the colon with a rectal tube or surgically may be required, if abdominal compartment syndrome is developing. Give Stress ulcer prophylaxis with intravenous pantoprazole or omeprazole, usually 40mg twice daily or as a continuous infusion of 8mg per hour. Thoracic epidural block is effective and safe, and will help reduce the dose of systemic opioids, although it is not widely used. Antibiotic prophylaxis: although at the beginning, pancreatitis is a non- infective condition, prevention of secondary bacterial infection in the necrotic areas is essential. The risk of giving prophylactic antibiotics is that it may speed up the selection of certain strains of Staphylococci and Enterococci, and may result in fungal overgrown and multi- resistant gram negative bacteria. Aspiration and culture of the necrotic areas should be performed, and if infection is confirmed, appropriate antibiotics must be given. Blood glucose control: hyperglycaemia must be controlled, usually using an insulin infusion. Hypocalcaemia often occurs, and must be corrected with infusions of calcium gluconate. Surgical drainage: indications for surgery are limited: x Infected pancreatic necrosis. Pancreatitis 250 Handbook of Critical Care Medicine x Severe retroperitoneal haemorrhage: this occurs due to erosion of a blood vessel by proteases. Surgery for removal of large sterile necrosis does not improve survival and is not recommended.

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Thus buy cheap viagra super active 50 mg on-line erectile dysfunction treatment herbal, strict liability subject to certain defenses purchase viagra super active 100mg mastercard erectile dysfunction treatments herbal, the Act created a regime would mean that pharmaceutical companies would of strict liability, although existing common law have to pay damages in some cases, even when they rights have remained unaffected, so that if the Act had researched their drugs impeccably (Hunter, does not apply to a particular case, a plaintiff may 1993). This has direct relevance to pharmaceutical companies, in Warranty is also a principle of both tort law and that most courts have agreed that a product will contract law, that allows a purchaser of a product not give rise to strict liability if it is unavoidably to bring a cause of action against the immediate unsafe, as described by labeled descriptions of ad- seller of that product if he/she can demonstrate that verse events, and its benefits can outweigh its the seller expressly or implicitly made representa- dangers. Thus, the seller may have reasonably and when the product is sold, and not on the date honestly believed that his/her representations or when the resulting product liability case comes to warranties were true, and could not possibly have trial. Section 3(2) of the facture a product is nonetheless held to have im- Act further provides that, in determining liability, pliedly warranted its merchantability by virtue of account will be taken of all the surrounding cir- the fact that he has sold it, assuming he deals in cumstances of the case, including the purposes for goods of that kind. The con- liability actions vary, based upon the respective cept of a duty of care serves to define the interests common law or statutory provisions of jurisdiction protected by the tort of negligence, by determining in which the action is filed. The damage in question may Regulatory Compliance arise through mis-feasance or non-feasance and may consist of personal injury or damage to prop- The issue of regulatory compliance as a defense in erty, which are categorized as pure economic loss product liability actions, especially those involving under civil law. It should also be noted that manu- pharmaceutical companies, generally arises in con- facturers, but also retailers, bailers, and other sup- nection with allegations of design or manufactur- pliers may be liable to plaintiffs under the ing defects or of failure to comply with federal principles of negligence if they are found to have labeling requirements. However, several states, such as New With regard to product liability claims, there are Jersey, have enacted statutes that allow regulatory two fundamental types of product defects: manu- compliance as a valid defense in pharmaceutical facturing defects and design defects. In contrast, design defects involve a product where all similar items manufactured by the defendant are Disclaimers the same, and they all bear a feature whose design is it defective and unreasonably dangerous. It With regard to product liability actions brought should also be noted that most design defect claims under the principles of warranty, a defendant may could be categorized as involving either structural assert a defense based upon a disclaimer from a defects, absence of safety features, or suitability for warranty associated with the purchase or use of unusual purposes. Therefore, to avoid liability, prescription drug makers need to ensure that information is provided promptly Contributory Negligence to physicians when an adverse drug reaction is discovered with one of their products (DeConinck A defense of contributory negligence asserts that a 1994). However, these foreigners to sue in their own country because if the plaintiff learns of the risk and voluntarily they do not have a claim there, or they are not able assumes the risk in purchasing and using the prod- to have their case heard for many years. During the course of litigation, a defense to strict liability, depending upon the pharmaceutical companies are now routinely degree of foreseeability of the abnormal use or faced with discovery requests, designed to identify misuse. A most critical information concerning drug safety few years later, chemists at another West German and efficacy is consistent throughout the world pharmaceutical company, Chemie Grunenthal, de- (Moore 1999). The ensuing studies revealed that thal- idomide was ineffective as an anticonvulsant, but In contrast to the ostensibly uniform framework of that it acted as a mild hypnotic or sedative. On the product liability law that defines drug-induced tort, basis of these data, Chemie Grunenthal brought the history of high-profile pharmaceutical injury thalidomide to market under the trade name Con- litigation shows that the practical prosecution of tergan on October 1 1957 (Robertson 1972). Thal- drug-related injury claims is broadly varied as it idomide was an early success; it acted quickly to reflects the many possible types of drug-induced cause deep, natural-feeling sleep, and the drug soon injuries. Although the breadth of potential harms became a favorite sleeping tablet for over-the- from the use of pharmaceuticals is, in theory, limit- counter consumers and for institutions. Also an anti- unpredictably severe or harmful effect on hyper- emetic, Contergan was commonly prescribed for sensitive individuals; (c) dependence, where users of the nausea of pregnancy (Sherman 1986; cf. Although thalidomide showed no toxicity need for the drug; (d) indirect injury, where the to laboratory animals when tested by Ciba and drug interferes with mental or physical functions, Chemie Grunenthal, potentially irreversible per- resulting in collateral injuries; (e) interactions, ipheral polyneuritis was soon identified in patients where ingesting the drug in the context of other following long-term use of thalidomide. Symptoms drugs or foods causes injury; (f) inefficacy, where included burning pain in the feet, cramping pain the drug fails to perform its intended function; in the calves, loss of ankle and knee reflexes, and and (g) socially adverse effects, where a drug (usu- tingling hands (Crawford 1994). Other reported ally an antibiotic) is overused by a population of toxicity symptoms included severe constipation, patients, resulting in the rise and spread of resistant dizziness, hangover, loss of memory, and hypoten- microorganisms (Dukes et al 1998). In the 1950s, though, until it became clear that the reports on neurotoxi- it was not common practice for drug companies to city were valid and that, in addition, thalidomide test new drugs on pregnant animals (Ferguson was adversely affecting unborn children. This was shocking news about a care it owed to all potential consumers of the drug, popular drug that was, at the time, marketed including the then-unborn plaintiffs. This claim, throughout Europe and Asia as a mild, safe seda- too, was questionable, however, in light of the con- tive and anti-emetic; alarmingly, thalidomide was temporaneous Hamilton v. In addition to phocomelia, proving that thalidomide was the teratogenic cause thalidomide babies suffered from spinal cord for each plaintiff given the spontaneous risk of defects, cleft lip or palate, absent or abnormal ex- abnormality inherent in human embryonic develop- ternal ears, and heart, renal, gastrointestinal or ment (See Ferguson 1992).

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Calcium deposits may first be an incidental finding on radiographs buy viagra super active 25mg online erectile dysfunction co.za, and the patient may be as- ymptomatic discount viagra super active 50 mg mastercard erectile dysfunction divorce. Patients may present with pain between 70 to 100 degrees of abduction and may have marked swell- ing and tenderness over the joint. The exam- iner may hold the arm at 90 degrees abduction and see if the patient can maintain the position (Drop Test). Plain film radiographs may show narrowing of <6 mm between the superior aspect of the humerus and the undersurface of the acromion (normal 7-14 mm). Acute tears are usually secondary to forced abduction and may be associated with glenohumeral dislocations (commonly inferior glenohumeral dislocations). Patients should receive ice, analgesia, sling immobilization and prompt orthopedic follow-up. Patients should receive analgesia and orthopedic follow-up for phys- iotherapy and possibly surgical correction. Orthopedic Emergencies 209 The Elbow Joint Anatomy and Function • The elbow joint is a hinge joint comprised of the distal humerus and the proximal ulna and radius. The elbow is capable of flexion and extension from 0 to 150o as well as supination and pronation. The radius articulates with the capitellum, the articulating surface of the lateral condyle. The lateral epicondyle is the origin of extensor and supinator muscles, the medial epicondyle gives rise to the flexor muscles. During extension, the olecranon fossa on the posterior aspect of the hu- merus receives the olecranon. The main function of the ulno-trochlear articulation is flexion-extension; the radio-capitellum joint is responsible for supination-pronation. The radial nerve runs posterolateral around the joint, coursing anteriorly as it moves distally down the radius. The ulnar nerve courses posterior to the medial condyle before mov- ing anterior-lateral in the forearm. Management 8 Prehospital Prehospital care entails immobilization to prevent further neurovascualar injury, elevation and ice. In addition to mechanism, inquire about onset, quality and radiation of pain (static or dynamic). Physical Exam Neurovascular exam is crucial especially if elbow dislocation is suspected. If dislo- cation has occurred, immediate reduction with sedation and analgesia is recom- mended. All lacerations in the vicinity of the elbow joint must be considered to involve the joint space until proven otherwise. Always remem- ber to identify other injury by examining the clavicle, shoulder, humerus, forearm, wrist and hand. In the lateral view, make special note of the posterior fat pad; even in occult fractures, the posterior fat pad will be 210 Emergency Medicine visible secondary to the displacement of the fat from the olecranon fossa by the effusion. False positives can occur if there is laxity of the triceps when the arm is not in true flexion.

Prevention program s are starved at least in part because medicine wants too m uch of the loaf viagra super active 25 mg without prescription severe erectile dysfunction causes. Prevention program s are also starved because medical care is often a “life and death” matter generic 50mg viagra super active with mastercard protocol for erectile dysfunction. No argum ents and no logic will convince terrified parents that the resources needed to treat their child would be m ore rationally allocated to prevention. Medicine could do far m ore to inform public opinion, but the problem would remain. This is why I argue, in some detail later, that our basic conceptions about health must change if medicine is to change. T he public’s value preferences are real; only when those value preferences change will medicine change. In combination, then, the empirical evidence and the theory seem convincing; medical care has a limited impact on health and is most effective when applied to certain identifiable conditions where there is evidence about its ef­ fectiveness. But when contrasted with all the other factors that demonstrably affect health, medicine plays a m inor role, despite being cast for lead. The Hippocratic era established the scientific foundation o f medicine four centuries before the Christian era. But all early medical systems blended the scientific with strong doses o f mystique. T he empirical side of medicine manifested a healthy respect for common but strikingly pragmatic practices. As Lord Ritchie-Calder ob­ served about Assyro-Babylonian medicine o f roughly 2000 B. The eye trouble was ascribed to the Demon of the Southwest wind, the image for which was a dog-headed eagle with lion’s claws. The wind was supposed to be frightened by the ugliness of his own image, which, accordingly, was set up outside the houses to keep him and his afflictions away. To treat sore eyes, the priest-doctor would prescribe cutting up an onion and mixing it and drinking it with beer. This was obvi­ ously to encourage tears, with (as we now know) their germici­ dal properties. Calder continues: So far this is commendable treatment but, by priestly reckon­ ing, not drastic enough against such a nasty demon. So to the straight-forward prescription was added the ritualistic one: “Thou shalt disembowel a yellow frog, mix its gall in curd and apply to the eye. It is dura­ bly wedded to the scientific m ethod, frequently to the detri­ m ent o f the “art” in medicine. Shamans perform ed theatrical stunts to sum m on spiritual support for their crude but often effective therapies. The Asclepian medical tradi­ tion, drawn from Greco-Roman history, also exemplifies this duality. Physicians trained in this tradition not only utilized drugs and some surgical techniques, but also invoked the gods to assist in the cure. For practidoners who possessed some competence in both, the m ixture of art and science probably worked. But when plied by practitioners with neither skill, or with only one of the two, it seems to have been disastrous. Medicine finally yielded to the “logic” o f the scientific method as it passed into this century. A sage physician has observed that “somewhere between 1910 and 1912 in this country, a random patient, with a random disease, consult­ ing a doctor chosen at random had, for the first time in the history of mankind, a better than fifty-fifty chance of profiting from the encounter.

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