Arthritis Australia

W. Leon. Wayland Baptist University.

Zileuton may double serum theophylline levels and theophylline dosages should be reduced and serum levels monitored in patients taking both drugs ( 119) cheap lipitor 10 mg with mastercard. Zafirlukast and montelukast are category B drugs in pregnancy; however lipitor 5mg with mastercard, current guidelines recommend the use of medications with which there has been more experience in pregnancy ( 120). Dosage and Preparations Zileuton is available in 600-mg tablets that are taken four times daily. Montelukast is available in 4- and 5-mg chewable tablets (for ages 2 6 and 6 15, respectively), and 10-mg tablets for ages 15 and older. The toxicity of these drugs has long been recognized, and is reflected in the common name Atropa belladonna, deadly nightshade, the plant from which atropine is derived. Scopolamine, another naturally occurring anticholinergic, is now used primarily in the treatment of motion sickness. Ipratropium bromide, a synthetic congener of atropine, is the only anticholinergic now in common use for asthma and chronic obstructive pulmonary disease. Cholinergic Mechanisms in Asthma The autonomic innervation of the airways is supplied by branches of the vagus nerve, which are found primarily in large and medium-sized airways. The postganglionic terminals of the vagal fibers supply smooth muscles of the airways and vasculature. Release of acetylcholine from the parasympathetic postganglionic fibers, acting on muscarinic receptors, results in smooth muscle contraction and release of secretions from submucosal glands ( 121). The activity of the cholinergic fibers results in a constant, low level of tonic activity of the airways ( 122). Mechanism of Action of Anticholinergics The anticholinergic agents compete with acetylcholine at muscarinic receptors. M1 and M3 receptors promote bronchoconstriction and mucus secretion, whereas M2 receptors promote bronchodilatation ( 123). All of the currently available anticholinergics nonselectively inhibit all muscarinic receptor subtypes ( 124). The blockade of M2 receptors may potentiate bronchoconstriction, which antagonizes the bronchodilatory effect of M1 and M3 receptor blockade ( 125,126). This has led to a search for selective drugs that do not antagonize the bronchodilatory effects of M2 receptors, but none is currently available. Because muscarinic receptors are found primarily in the central airways, anticholinergic bronchodilatation occurs mostly in the larger airways (127,128). The anticholinergics provide virtually complete protection against bronchoconstriction induced by cholinergic agonists such as methacholine ( 126,127). Pharmacology Atropine is well absorbed from mucosal surfaces and reaches peak serum levels within an hour. Atropine relaxes smooth muscle in the airways, gastrointestinal tract, iris, and peripheral vasculature. Atropine crosses the blood brain barrier and can cause central nervous system side effects. Scopolamine has similar pharmacologic properties, but is even more likely to cause central nervous system side effects at low doses (130). The quaternary ammonium structure allows for poor absorption across respiratory and other mucous membranes (131). This results in a lack of significant anticholinergic side effects and allows ipratropium to remain in the airways longer than atropine. Ipratropium does not cross the blood brain barrier or inhibit mucociliary clearance ( 131,132). Efficacy Anticholinergics are less effective bronchodilators than b-adrenergic agonists. Peak bronchodilatation occurs 30 to 90 minutes after inhalation of ipratropium, compared with 5 to 15 minutes after inhalation of albuterol ( 133). Some patients may respond better to ipratropium than to albuterol, but there are no reliable predictors for which patients respond well to ipratropium (134,135). Anticholinergic agents are superior to b-adrenergic agonists in preventing bronchospasm induced by b blockers or psychogenic bronchospasm (135,136,137 and 138). Ipratropium bromide appears to improve outcomes when added to albuterol in emergency treatment of acute exacerbations of asthma, but the additional effect is not always large ( 139). Ipratropium bromide nasal spray relieves rhinorrhea associated with allergic ( 140) or nonallergic rhinitis ( 141) and viral upper respiratory infections ( 142). Safety and Drug Interactions Atropine may cause significant side effects, even at therapeutic doses. Warmth and flushing of the skin, impairment of mucociliary clearance, gastroesophageal reflux, and urinary retention are common. Central nervous system effects ranging from irritability to hallucinations and coma may occur. Tahyarrhythmias may occur at low doses, and atrioventricular dissociation may occur at high doses. Because of the frequency of side effects, potential for severe toxicity, and availability of drugs with superior safety and efficacy, there is no role for atropine in the management of asthma; it is mainly used to treat symptomatic bradycardia and reverse organophosphate poisoning. Ipratropium bromide has no severe adverse effects or drug interactions and is very well tolerated.

So do other parts of the body: it is striking that those who are willing to donate their kidneys for transplantation after 7 death may nonetheless withhold consent for other body parts purchase lipitor 40 mg on line, in particular hearts and eyes (corneas) purchase lipitor 40 mg with amex. Yet the demand for bodily material, whether for medical treatment or for research, remains as pressing as ever. Attitudes towards medicine and medical care have been changing as well, in the context of a general shift in society towards a greater focus on care of the self, and the role of the 11 patient in determining how health services should be delivered, and the increasing expectation that medicine will be able to intervene to overcome problems formerly regarded as insoluble. While the general shift in attitudes to health care may have led to a new kind of awareness of the body and its potential value to others, there is little evidence to suggest that this has discouraged people from donating freely: we note, for example, that organ donation is on the increase. We are dealing with an issue that does not seem to go away the demand for bodily material for medical treatment and research. However, bodily material is not like any other, and the question of how it is obtained and used raises all kinds of further questions. This is where, for instance, the unpaid and voluntary nature of donation comes in: why is this aspect valued, and what are the ethical concerns to which this emphasis has been the response? The Working Party was asked to identify and consider the ethical, legal and social implications of transactions involving human bodies and bodily material in medical treatment and research. It was also asked to consider what limits there should be, if any, on the promotion of donation or volunteering. See also: Nature Immunology Editorial (2010) Reduce, refine, replace Nature Immunology 11: 971. In this report we attempt to assist deliberation on these questions, and to throw light on the tensions that arise when it comes to reconciling public need with individual feelings on the matter. As one respondent to the consultation commented: Human biological samples can ultimately be provided only by individuals, not by organisations. If individuals do not accept that responsibility in sufficient 15 numbers, the current system will fail. We therefore highlight both the international dimension (for example where international statements or agreements exist) and examples of the diverse regulatory approaches taken in other jurisdictions. Nor do we consider the specific issues raised by genetic research, although our general comments on research using bodily material will in many cases also be relevant for genetic research. Rather, it has taken the view that much may be learned from comparing different forms of donation, their different regulatory structures, and the ethical assumptions that underpin these structures. Such comparisons 15 Professor Peter Furness, responding to the Working Partys consultation. If one factor that unites the many different forms of material covered in this report is that they have a 19 single source (the body of a person), another is that the desired outcome of these actions is benefit 20 to others, whether or not these others are in mind at the time. We have already noted possible distinctions between bodily material from living individuals and bodily material from deceased individuals; and, indeed, the way the law now makes relatively little distinction between these has been the subject of complaint by some clinicians. Other key distinctions relate to the inducements or incentives that are permissible in the context of encouraging people to participate in these forms of bodily donation, and to the degree of control that the donor may have over the future use of what has been donated. At first sight, there may appear to be very clear distinctions between the two cases that more than explain the regulatory differences. Such developments bring their own ethical challenges: in particular, they highlight the crucial role played by transactions and intermediaries in the sphere of donation. Diverse intermediaries (specialist nurses, transport services, technical and ancillary staff to name just a few) are involved in processing the material to facilitate its use by the end- recipient. Thus, while we note that potential donors are often encouraged to come forward by agencies focusing on the needs of a single symbolic recipient, any consideration of policy surrounding donation must take into account the complex transactions and multiple intermediaries involved in the process. The person providing the material may be living or deceased; the material may be used almost immediately or stored for long periods of time; the material may be used raw or heavily processed; the material may be used in the direct treatment of others or for research purposes; the recipient may be an individual patient, or research organisation; the material itself may be healthy or it may be diseased. For as long as bodily health is generally recognised as a marker of personal well-being, there will be a need for society to do what it can to promote the practice of medicine and pursue research into the functioning of the human body. This chapter provides an overview of these issues, and suggests that a comparative approach, identifying both similarities and distinctions in the nature and use of these materials, may help to illuminate and explain many of the ethical concerns that arise in connection with these practices. Any attempt to divide these various forms of bodily material into discrete categories is inevitably imperfect, given the complex and overlapping relationships between them. However, in this report we follow common non-clinical usage in separating out solid organs and blood from other forms of tissue. Donated blood may be used for research if not needed for treatment, and samples of blood will often be taken during medical investigations, as part of a clinical trial or other research project, or in the context of population or longitudinal studies (see paragraphs 1. Blood is classified into four main groups, and giving 28 someone blood from the wrong group may be life-threatening. Plasma may also be processed into a range of medical products, including immunoglobulins (antibodies) to provide protection from disease for patients with low levels of antibodies, coagulation factors (to improve blood clotting) and albumin (used for restoring blood volume). While such material can be deployed in many ways, and may undergo modification, it can only be obtained from a person. Small quantities of adult stem cells are found in organs, tissues and fluids such as heart, brain and fat, as well as in cord blood. Adult cells of various kinds, for example skin cells, can also be transformed into pluripotent stem cells by the introduction of the factors found to be active in embryonic stem cells (see paragraph 1. Adults who volunteer to donate stem cells through the bone marrow registries may either donate stem cells from circulating blood (which involves being injected with a drug to increase significantly the number of stem cells in the circulating blood), or bone marrow itself, which involves the removal of stem cells from hip bones under general 35 anaesthesia.

Simple measures to reduce exposure to house dust and dust mite through the elimination of bedroom carpeting and special casings for the bedding are clinically effective and pose no undue hardship on the patient and family order lipitor 5mg with amex. Similar measures can be taken to reduce indoor air levels of mold spores and other allergens buy lipitor 40 mg fast delivery, efficiently and cheaply in most cases. In contrast, the concept of multiple food and chemical sensitivities discussed below carries with it a recommendation for extensive avoidance of environmental chemicals. There no proof that these drastic measures are helpful; on the contrary, there is evidence for significant psychologic harm ( 52). Antifungal Medications The unsubstantiated theories of Candida hypersensitivity syndrome and disease caused by indoor molds, both discussed below, have prompted some physicians to prescribe a treatment program of antifungal medications and a special mold-free diet. Nystatin is usually prescribed first in a powder form given in a minute dose orally, followed by ketoconazole if the desired effect is not achieved. Although these drugs are effective in the treatment of cutaneous and systemic candidiasis, their use in the unsubstantiated Candida syndrome cannot be justified, and a controlled clinical trial showed that nystatin did not differ from placebo in its effect on such patients (53). Immunologic Manipulation Allergic diseases affect a minority of the population exposed to allergens. Allergen avoidance prevents disease but without altering the underlying immunologically induced hypersensitive state. Allergen immunotherapy, discussed elsewhere in this book, does not achieve this goal, although it is clinically beneficial in most cases. Therapeutic gammaglobulin injections are a standard treatment for documented IgG antibody deficiency, and they have proved effective for this purpose. They are effective in idiopathic thrombocytopenic purpura and in Kawasaki disease, although the mechanism of efficacy is unknown. Gammaglobulin injections are being recommended by some practitioners for allergy, but until effectiveness is shown by proper double-blind studies, such treatment should be considered experimental. Some unconventional methods of diagnosis and treatment are based on conventional theories, others on unsubstantiated theories arising from empirical observations, and still others appear to lack any theoretical basis. Allergic Toxemia Allergic diseases are characterized by focal inflammation in certain target organs such as the bronchi in asthma; the nasal mucosa and conjunctivae in allergic rhinitis; the gastrointestinal mucosa in allergic gastroenteropathy; the skin in atopic dermatitis, urticaria, and allergic contact dermatitis; and the lung parenchyma in hypersensitivity pneumonitis. Multiple target organs are involved in systemic anaphylaxis and in serum sickness. During the course of illness, the allergic patient with localized disease may experience systemic symptoms such as fatigue or other focal symptoms (such as headache) in parts of the body not directly involved in the allergic inflammation. These collateral symptoms are sometimes explainable pathophysiologically, for example as secondary effects of hypoxemia and hyperventilation in asthma or from cranial and neck muscle tension because of excessive sneezing in rhinitis. Furthermore, it is possible that locally released inflammatory mediators and cytokines may produce systemic effects, although direct proof of this is lacking. The allergens most often implicated in this concept are foods, environmental chemicals, food additives, and drugs. This syndrome has been referred to as allergic toxemia, allergic tension fatigue syndrome ( 54), or cerebral allergy (55). No definitive controlled studies have yet shown the existence of such a syndrome ( 16). Although there are frequent claims of dramatic improvement with the elimination of certain foods or chemicals, these claims are not supported by scientific evidence. An extension of the allergic toxemia concept is the proposal that allergy is the cause of certain psychiatric conditions. According to one theory, attention deficit disorder in children is caused by food coloring and preservatives ( 56). This concept was embraced by certain physicians and parents who recommended and used food additive free diets for hyperactive children. There are also reports claiming that ingestion of certain foods, particularly wheat, is a cause or contributing factor to adult schizophrenia ( 58,59). Idiopathic Environmental Intolerances (Multiple Chemical Sensitivities) In recent years, a small group of physicians have promoted a practice based on the theory that a wide range of environmental chemicals cause a variety of physical and psychological illnesses; symptoms involving the musculoskeletal system, joints, and gastrointestinal tract; and a host of nonspecific complaints in patients who have no objective physical signs of disease. The same patients typically blame multiple food sensitivities as a cause of these symptoms. The practice based on these ideas is known as clinical ecology ( 50,60,61), which postulates that these patients suffer from failure of the human species to adapt to synthetic chemicals (62). One theory proposes that symptoms represent an exhaustion of normal homeostasis, caused by ingestion of foods and inhalation of chemicals. Another theory proposes that common environmental substances are toxic to the human immune system (63). The recent term idiopathic environmental intolerances is the most accurate name because it does not include any of the proposed but unproved mechanisms (64). Patients with this diagnosis generally have a wide range of symptoms that are often compatible with conversion reactions, anxiety and depression, or psychosomatic illness.

Thus order lipitor 40 mg amex, Miles accepts that the moral standards The Hippocratic Oath and Contem porary Medicine 115 of medicine must be reevaluated in the light the historical development of society but likewise suggests that the Oath ought not to be regarded as an old relic relevant for past medical practitioners of Ancient Greece generic 40mg lipitor amex. The Oath, he claims, can still teach us one medical ethic among competing moral systems. It is only insofar as one is able to understand (thus, 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. 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. This would require relocating the analysis of the moral questions raised by med- icine within the context of a philosophy of medicine.