By F. Reto. Grinnell College.

Further results concerning the benefits of breast screening have been reported following a large random controlled trial in Sweden (Lundgren 1981) generic propranolol 80 mg overnight delivery cardiovascular disease kidney disease. Hinton (1992: 231) concluded from his review of the literature that ‘lives may be saved by annual mammographic screening’ buy propranolol 40mg online cardiovascular x-ray. In addition, the identification of the absence of illness through screening may also benefit the patient in that a negative result may ‘give health back to the patient’ (Grimes 1988). Therefore, according to the ethical principle of beneficence, screening may have some positive effects on those individuals being screened. Evidence against beneficence Electronic foetal monitoring was introduced as a way of improving obstetric outcomes. However, the results from two well-controlled trials indicated that such monitoring may increase the rate of Caesarean section without any benefit to the babies both immediately after birth (MacDonald et al. In a recent review of the effects of antenatal blood pressure screening on the incidence of pre-eclampsia (high blood pressure in pregnancy, which threatens the mother’s life), the authors concluded that the introduction of antenatal screening has had no significant effect on pre-eclampsia, suggesting that this screening process does not benefit the individual. Recent papers have also questioned the efficacy of screening for congenital dislocation of the hip in neonates (Leck 1986), hypertension, breast cancer and cervical cancer in terms of the relative effectiveness of early (rather than later) medical interventions and the effects of simply increasing the lead time (the period of time between detection and symptoms). Non-maleficence – screening must do no harm Skrabanek (1988) suggested that screening should be subjected to the same rigours as any experimental procedure, that the possible risks should be evaluated and that the precept of ‘first do no harm’ should be remembered. Therefore, for screening to be ethical, it must not only benefit the patient, but it must also have no negative consequences either to the individual or to society as a whole. The psychological and financial consequences of screening will be dealt with under later headings. However, screening may cause personal harm in terms of biological consequences and false-negative (receiving a negative result when the problem is actually present) or false-positive (receiving a positive result when the problem is actually absent) results; it may also cause social harm in terms of the medicalization of popula- tions and the exacerbation of the existing stigmatization of certain groups of individuals. Personal harm Some of the techniques used to monitor an individual’s health may have a detrimental effect on their biological state. This is of particular concern for the frequent use of mammography for the detection of breast cancer. Evidence for the harmful effects of the irradiation of breast tissue and the links to cancer can be found in reports of breast cancer in women who have been treated for benign conditions using radiation therapy (Metler et al. It has been argued that there is a threshold, below which radiation could be considered totally safe, and that the above examples of an association between irradiation and breast cancer are due to the unusually high levels of radiation (Perquin et al. Furthermore, Strax (1978) suggested that if 40 million women were screened for 20 years, 120 would die from radiation-induced breast cancer. However, since these concerns were raised, the dose of radiation used in mammography has been reduced, although some concerns still remain. A false-negative result may lead to an illness remaining undetected, untreated and con- sequently progressing without medical intervention. Social harm Zola (1972) has argued that medicine is a means of social control and suggested that there is a danger if individuals become too reliant on experts. In terms of screening, monitoring and surveillance of populations could be seen as a forum for not only examining individuals but controlling them. This argument is also made by Illich (1974) in his book Medical Nemesis, where he argued that medicine is taking over the responsibility for people’s health and creating a society of medical addicts. Screening epitomizes this shift towards social control in that not only are the ill seen by the medical profession but also the healthy as all individuals are now ‘at risk’ from illness (Armstrong 1995). Skrabanek (1988: 1155) argued that screening and the medicalization of health ‘serves as a justification for State intrusion into people’s private lives, and for stigmatising those who do not conform’. The possibility that screening may exacerbate existing stigma of particular social groups is particularly relevant to the screening for genetic disorders. At present, society is constituted of a variety of individuals, some of whom have genetic deficits such as Down’s syndrome, cystic fibrosis and sickle-cell anaemia. Although these individuals may be subjected to stereotyping and stigma, society provides treatment and support and attempts to integrate them into the rest of the population. It is possible, however, that screening for such disorders would lead to terminations of pregnancy and a reduction in this stigmatized population. Although this would lead to fewer individuals with these disorders (this may be a positive consequence, as no one wants to suffer from sickle-cell anaemia) the individuals who are born with these problems may face increased stigma as they would be part of a greatly reduced minority existing in a world with reduced social provisions for support and treatment. Autonomy – the patient has a right to choose The third ethical principle is that of autonomy.

Structure provides security cheap propranolol 40 mg fast delivery cardiovascular unit nurse, and one or two activities may not seem as over- whelming as the whole schedule of activities presented at one time order propranolol 80 mg free shipping coronary heart disease usa. Establish a system of rewards for compliance with therapy and consequences for noncompliance. Posi- tive and negative reinforcements can contribute to desired changes in behavior. Convey acceptance of client separate from the undesirable behaviors being exhibited. Onset of the disorder can be as early as 2 years, but it occurs most commonly during childhood (around age 6 to 7 years). The symptoms usually diminish during adolescence and adulthood and, in some cases, disappear altogether by early adulthood. Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence ● 43 Predisposing Factors 1. Family studies have shown that Tourette’s dis- order is more common in relatives of individuals with the disorder than in the general population. It may be transmitted in an autosomal pattern intermediate between dominant and recessive (Sadock & Sadock, 2007). Altered levels of neurotransmitters and dysfunction in the area of the basal ganglia have been implicated in the etiology of Tourette’s disorder. The genetic predisposition to Tourette’s disorder may be reinforced by certain factors in the environ- ment, such as complications of pregnancy (e. The disorder may begin with a single motor tic, such as eye blinking, neck jerking, shoulder shrugging, facial grimacing, or coughing. Complex motor tics may follow and include touching, squat- ting, hopping, skipping, deep knee bends, retracing steps, and twirling when walking. Vocal tics include various words or sounds such as clicks, grunts, yelps, barks, sniffs, snorts, coughs; in about 10% of cases, a complex vocal tic involves uttering obscenities. Vocal tics may include repeating certain words or phrases out of context, repeating one’s own sounds or words (palilalia), or repeating what others say (echolalia). The movements and vocalizations are experienced as compul- sive and irresistible, but they can be suppressed for varying lengths of time. Tics are exacerbated by stress and attenuated during periods in which the individual becomes totally absorbed by an activity. Client will seek out staff or support person at any time if thoughts of harming self or others should occur. Recog- nition of behaviors that precede the onset of aggression may provide the opportunity to intervene before violence occurs. Provide hand coverings and other restraints that prevent client from self-mutilative behaviors. Excess energy is released through physical activities and a feeling of relaxation is induced. Children on this medica- tion must be monitored for adverse effects associated with most antipsychotic medications (see Chapter 28). Because of the potential for adverse effects, haloperidol should be reserved for children with severe symptoms or with symptoms that interfere with their ability to function. The response rate and side effect pro- file of pimozide are similar to those of haloperidol. It is used in the management of severe motor or vocal tics that have failed to respond to more conventional treatment. Clonidine is an antihyperten- sive medication, the efficacy of which in the treatment of Tourette’s disorder has been mixed. Some physicians like it and use it as a drug of first choice because of its rela- tive safety and few side effects. Atypical antipsychotics are less likely to cause extrapyramidal side effects than are the older antipsychotics (e. Risperidone, the most studied atypical antipsy- chotic in Tourette’s disorder, has been shown to re- duce symptoms by 21% to 61% compared with placebo (results that are similar to those of pimozide and cloni- dine) (Dion et al. Both olanzapine and ziprasi- done have demonstrated effectiveness in decreasing tic symptoms of Tourette’s disorder. Long-term Goal Client will be able to interact with staff and peers using age- appropriate, acceptable behaviors.

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For example discount 40mg propranolol cardiovascular system chapter 11, blows to the scalp with the circular head of a hammer or the spherical knob of a poker tend to cause crescent-shaped lacera- tions purchase propranolol 80 mg mastercard cardiovascular system nutrition. A weapon with a square or rectangular face, such as the butt of an axe, may cause a laceration with a Y-shaped split at its corners. Incisions These wounds are caused by sharp cutting implements, usually bladed weapons, such as knives and razors, but sharp slivers of glass, the sharp edges of tin cans, and sharp tools, such as chisels, may also cause clean-cut incised injuries. Axes, choppers, and other similar instruments, although capable of cutting, usually cause lacerations because the injury caused by the size of the instrument (e. Mixed wounds are common, with some incised element, some laceration, bruising, and swelling and abrasion also present. Machetes and other large-blade implements are being used, pro- ducing large deep cuts known as slash or chop injuries. They Injury Assessment 141 gape, and the deeper tissues are all cut cleanly in the same plane. If the blade of the weapon is drawn across the skin while it is lax, it may cause a notched wound if the skin creases. The direction of travel of the blade of the weapon is not always easy to decide, but usually the deeper part of the wound is near the end that was inflicted first, the weapon tending to be drawn away toward the end of the wound. In an attempt to ward off the assailant, the arms are often raised in a protective gesture and incisions are then often seen on the ulnar borders of the forearms. If the blade of the weapon is grasped, then incised wounds are apparent on the palmar surfaces of the fingers. Incised wounds may be a feature of suicide or attempted suicide (see Subheading 3. They are usually located on the wrists, forearms, or neck, although other accessible areas on the front of the body may be chosen. The incisions usually take the form of multiple parallel wounds, most of them being tentative and superficial; some may be little more than simple linear abrasions. Stab Wounds Stab wounds are caused by sharp or pointed implements and wounds with a depth greater than their width or length. They are usually caused by knives but can also be inflicted with screwdrivers, pokers, scissors, etc. Although the external injury may not appear to be particularly serious, damage to vital struc- tures, such as the heart, liver, or major blood vessels, can lead to considerable morbidity and death, usually from hemorrhage. In those individuals who survive, it is common for little information to be present about the forensic description of the wound because the priority of resuscitation may mean that no record is made. If operative intervention is undertaken, the forensic signifi- cance of a wound may be obliterated by suturing it or using the wound as the entry for an exploratory operation. In such cases, it is appropriate to attempt to get a forensic physician to assess the wound in theatre or subsequently. Stab wounds are rarely accidental and occasionally suicidal, but usually their infliction is a result of criminal intent. In the case of suicide, the wounds are usually located on the front of the chest or upper abdomen and, as with self- inflicted incisions, may be associated with several superficial tentative punc- ture wounds (see Subheading 3. When deliberately inflicted by an assailant, stab wounds may be associated with defense injuries to the arms and hands. The appearance of the skin wound will vary depending on the weapon used and can easily be distorted by movement of the surrounding skin. If the blade is double- edged, such as that of a dagger, the extremities of the wound tend to be equally pointed. A stab wound from a single-edged blade, such as a kitchen knife, will usually have one extremity rounded, squared-off, or fish-tailed (caused by the noncutting back of the blade). When blunt weapons are used—a pair of scissors, for example—the wound tends to be more rounded or oval, with bruising of its margins (see Fig. Scissor wounds can sometimes have a cross-shape caused by the blade screws or rivets. Notched wounds are often caused by the blade of the weapon being partially withdrawn and then rein- troduced into the wound or twisted during penetration.

Bieliauskas (1980) highlighted a relationship between depression and cancer and suggests that chronic mild depression purchase propranolol 40mg otc blood vessels under eye dark circles, but not clinical depression may be related to cancer propranolol 40mg low cost cardiovascular weight loss. Over the past few years there has been some interest in the relationship between personality and cancer. Temoshok and Fox (1984) argued that individuals who develop cancer have a ‘type C personality’. A type C personality is described as passive, appeasing, helpless, other focused and unexpressive of emotion. Eysenck (1990) described ‘a cancer-prone personality’, and suggests that this is characteristic of individuals who react to stress with helplessness and hopelessness, and individuals who repress emotional reactions to life events. An early study by Kissen (1966) sup- ported this relationship between personality and cancer and reported that heavy smokers who develop lung cancer have a poorly developed outlet for their emotions, perhaps suggesting type C personality. At follow-up they described the type of individual who was more likely to develop cancer as having impaired self-awareness, being self-sacrificing, self-blaming and not being emotionally expressive. The results from this study suggest that those individuals who had this type of personality were 16 times more likely to develop cancer than those individuals who did not. However, the relationship between cancer and personality is not a straightforward one. It has been argued that the different personality types predicted to relate to illness are not distinct from each other and also that people with cancer do not consistently differ from either healthy people or people with heart disease in the predicted direction (Amelang and Schmidt-Rathjens 1996). Low control suggests a tendency to show feelings of helplessness in the face of stress. Commitment is defined as the opposite of alienation: individuals high in commitment find meaning in their work, values and personal relationships. Individuals high in challenge regard potentially stressful events as a challenge to be met with expected success. The emotional state of breast cancer sufferers appears to be unrelated to the type of surgery they have (Kiebert et al. However, persistent deterioration in mood does seem to be related to previous psychiatric history (Dean 1987), lack of social support (Bloom 1983), age, and lack of an intimate relationship (Pinder et al. Women with breast cancer often report changes in their sense of femininity, attractiveness and body image. This has been shown to be greater in women who have radical mastectomies rather than lumpectomies (e. Cognitive responses Research has also examined cognitive responses to cancer and suggests that a ‘fighting spirit’ is negatively correlated with anxiety and depression whilst ‘fatalism’, ‘helplessness’ and ‘anxious preoccupation’ is related to lowered mood (Watson et al. First, they made a search for meaning, whereby the cancer patients attempted to understand why they had developed cancer. Meanings that were reported included stress, hereditary factors, ingested carcinogens such as birth control pills, environmental carcinogens such as chemical waste, diet, and a blow to the breast. Second, they also attempted to gain a sense of mastery by believing that they could control their cancer and any relapses. Such attempts at control included meditation, positive thinking, and a belief that the original cause is no longer in effect. This involved social comparison, whereby the women tended to analyse their condition in terms of others they knew. Taylor argued that they showed ‘downward comparison’, which involved comparing themselves to others worse off, thus improving their beliefs about their own situation. According to Taylor’s theory of cognitive adaptation, the combination of meaning, mastery and self-enhancement creates illusions which are a central component of attempts to cope. Psychosocial interventions have therefore been used to attempt to alleviate some of the symptoms of the cancer sufferer and to improve their quality of life. One of the main roles of psychology is in terms of pain management, and this has taken place through a variety of different pain manage- ment techniques (see Chapter 12). Turk and Rennert (1981) encouraged patients with cancer to describe and monitor their pain, encouraged them to develop coping skills, taught them relaxation skills, encouraged them to do positive imagery and to focus on other things. They reported that these techniques were successful in reducing the pain experience.

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