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By: Thomas Richard Gehrig, MD

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Lateral traction may be added in selected cases to further distract the articular surfaces treatment yeast infection home generic isoniazid 300 mg mastercard. Advantages of the lateral decubitus position l the lateral decubitus position allows for ergonomic technique in shoulder operations 340b medications generic isoniazid 300mg line. Procedure l the patient is placed in a reverse” position with the head on the footboard of the operating table medications jejunostomy tube order isoniazid overnight delivery. One disadvantage of this position is that surgical access to the joint is not as ergonomic as in lateral decubitus medicine quetiapine order isoniazid canada. The beach chair position also limits the scope of intraoperative participation by assistants medicine qd buy isoniazid 300 mg on line. It is advantageous in that it permits a full range of passive arm motion symptoms intestinal blockage discount isoniazid 300mg with amex, lowers the risk of traction injuries, and makes it much easier to convert to an open operation (Fig. Relative advantages and disadvantages of the beach chair and lateral decubitus positions Beach chair Lateral decubitus Conversion to an + – open operation Ergonomics – + Visualization of the joint (+) + Visualization of the + + subacromial space Intra-articular orientation – + Subacromial orientation Fig. Additional sterile marker so that the arthroscopist can maintain portal sites depend on the location of the standard anatomical orientation throughout the procedure, even posterior portal used for the arthroscope. Incorrect when overlying soft tissues become distended due to portal placement not only carries a risk of injury to fluid extravasation. Aided by the palpation of bony landmarks, the surgeon should be able to achieve optimum alignment and anatomical positioning of the arthroscope. Part I – Positioning and Approaches 9 Key Anatomical Landmarks l Lateral clavicle l Acromioclavicular joint l Acromion (usually its posterolateral corner) l Coracoid process l Scapular spine Fig. The posterior circumflex humeral artery accompanies the axillary nerve in its course through the axillary quad rangular space. The surgeon must be aware of these anatomical relationships to prevent iatrogenic injuries in the posterior approach (Figs. The posteromedial portal, first described by Caspari3, the anteromedial approach described by Wolf is located below the portal described by Andrews1,2, the anteromedial portal traditional posterior approach. The approach described described by Snyder, and the anteroinferior portal by Neviaser is a transmuscular portal created through described by Wolf4. A variety of sites and tech niques have been described for creating the posterior portal, all of them defining the posterolateral corner of the acromion as anatomical reference1, 2, 5. Whenever possible, the arthroscope should be intro duced parallel to the glenoid to ensure optimum mobility and good visualization of the joint (Figs. While the tip of the fluid instillation needle does pose a risk of iatrogenic cartilage injury, omitting preliminary distention of the joint capsule may make insertion of the trocar more difficult. After distending the joint with Ringer lactate solution in the first 200 shoulder arthroscopies performed at our institution, we have gained enough experience that our current practice is to omit initial fluid instillation. On the other hand, preliminary fluid distention may aid the experienced arthroscopist in passing the arthro Fig. These landmarks make it easier to localize the soft spot” between the infraspinatus and teres minor muscles, which can be identified by palpation in the posterior joint plane (Fig. The joint plane is easily identified in the relaxed shoulder by placing light pressure on the upper humerus while gently moving it forward and backward (Figs. Part I – Positioning and Approaches 13 After identifying the soft spot,” the surgeon introduces the operating cannula through the posterior portal site, guiding it anteriorly toward the coracoid process (Fig. After the cannula has passed through the tissue layer between the teres minor and infraspinatus muscles, the joint capsule will offer some degree of resistance that varies in different patients. Gentle pressure is applied to the operating cannula to penetrate the joint capsule (Fig. Warning: Malpositioning of the portal site and/or misalignment of the operating cannula involves the risk of injury to the humeral head, glenoid, and surrounding soft tissues. The arthroscope has been introduced through the posterior portal and is trained on the the location of the anatomical landmarks should be area of the biceps insertion. Advancement of the trocar tip is facilitated by placing gentle counterpressure on the anterior side of the humeral head with the nondominant hand. After the cannula has penetrated the joint capsule, the obturator is withdrawn and the arthroscope with video camera attached is introduced into the cannula, which remains in place. Once the shoulder joint has been distended with fluid, proper intra-articular placement of the arthroscope should be confirmed endoscopically via the monitor image of the shoulder joint (Fig. According to Andrews, the posterior portal is located the following distances from neurovascular structures that are potentially at risk: l 2–4 cm from the axillary nerve l 2–4 cm from the posterior circumflex humeral artery Fig. Outside-In-Technique Precise anatomical placement of the anterior portal depends directly on the placement of the initial posterior portal. Critical factors include patient position, the degree of arm abduction and flexion, and the location of the skin incision for the anterior portal. The anterosuperior portal is established approxi mately 1–2 cm anterior to the acromioclavicular joint and inferior to the long biceps tendon (Figs. The optimum site for this introduced using the technique described above, the portal depends directly on the posterior portal that was Wissinger rod is inserted through the posterior portal placed initially. The Wissinger rod is then advanced slightly defined penetration site in the joint capsule under farther into the joint space while the telescope with videoendoscopic control. Then, the camera is removed camera attached is reintroduced through the optical and replaced with a Wissinger rod”, leaving the optical shaft – previously withdrawn by about 1 cm – to shaft in place. After the cannula has the capsule and soft-tissue into the subcutis, and the been correctly positioned, the rod is removed from skin directly over the tip of the rod is incised with a the joint. The anteroinferior optical shaft may then be advanced over the Wissinger rod into the interior of the joint (Fig. Because proper intra-articular placement of the optical shaft cannot be accurately assessed in this situation, we recommend the following technique: a b F Figs. Part I – Positioning and Approaches 17 Outside-In-Technique the portal is situated just lateral to the coracoid process1,2. The position may be read Portals should never be placed medial to the justed until the needle penetrates the capsule at coracoid process! The mandrel is withdrawn from the positioning indications, but all portals should be placed with needle. A 1-mm Kirschner wire is introduced through the They should be created only by an adequately skilled positioning needle into the joint. The portals are created under arthroscopic control, which allows for optimum, accurate subsequent positioning of the operating cannula. Part I – Positioning and Approaches 19 Kirschner wire Skin incision Arthro scope Fig. The needle is removed from the joint while the guide wire is and in the correct alignment, the mandrel can be removed. As this is done, the soft-tissue is carefully dilated until the distal end of the operating cannula can be felt to pop” through the joint capsule. The portal is sometimes referred to from the operative shoulder to provide extra space for as supraspinatus portal or Neviaser portal3, 7. Before pressure-controlled irrigation pumps were used A slight anterior orientation of the head may facilitate in arthroscopy, Neviaser described a supraclavicular accurate portal placement (Fig. The acromial end of the clavicle and the opposing part the suprascapular notch, which is traversed by both of the acromion serve as anatomical landmarks. They structures, is located 2 cm medial and slightly anterior form two sides of a triangle whose apex marks the to the portal site (Figs. The location of the superior the Neviaser portal provides excellent visual exposure portal is easily identified by palpating with the finger of the superior portion of the joint and can be used for along the lateral border of the clavicle. Distance between the suprascapular nerve and Neviaser portal, shown in a human anatomical specimen. Thus, surgeons who routinely abduct the arm past 30° during the procedure should decrease the degree of arm abduction when creating a Neviaser portal. This is particularly important in to permit the faster, safer, and less traumatizing use complex repairs and reconstructions. The semi-open can be accomplished without difficulty by using the design of the device allows it to function as an intro following technique: ducer for other instruments. The Half Pipe is advanced percutaneously along an instrument already in place First, the arthroscope with camera attached is (Fig. Then, the optical shaft instrument is withdrawn, and another instrument can is removed, and a new operating cannula is intro then be introduced through the Half Pipe. If an anterior portal has already been created, the Wissinger rod is advanced through the operating Advantages cannula into the joint, and then the optical shaft is exchanged for the operating cannula. After the Access to the shoulder joint for arthroscopic recon Wissinger rod is removed, the arthroscope with structive surgery can be established with various video camera attached is introduced into the shaft. The advantage of the Half Pipe system is that intra-articular access through inspected through this portal. The portals can be switched as often as desired using the flexible handling of intra-articular instruments is the above technique. Access to the interior of the joint greatly facilitated by the fact that it is no longer strictly is easily maintained, even in patients with pronounced necessary to leave the operating cannula in place in swelling of the shoulder. The arthroscope with video camera attached Keeping the optical shaft in close contact with the is inserted as far the aforementioned anatomical undersurface of the acromion will usually prevent landmark, then passed underneath until reaching the iatrogenic injury to the underlying rotator cuff (Fig. Note: Note: Approximately four-fifths of the optical shaft should As a safety precaution, the scope should be passed be within the subacromial space following insertion, beneath the coracoacromial ligament to avoid as the subacromial bursa is mostly anteroinferior to iatrogenic injury to the acromial branch of the thora the acromion and may limit visibility in the posterior coacromial artery, which could obscure arthroscopic portion of the subacromial space. After the blunt obturator has been removed from the operating cannula and replaced by the arthroscope with video camera attached, the subacromial space is distended with copious irrigation fluid. Two types of subacromial portal are routinely used: l Anterior portal l Lateral portal Fig. Part I – Positioning and Approaches 25 the arthroscope with video camera attached is Outside-In-Technique replaced with a Wissinger rod, which is introduced As in the previous technique, the surgeon performs the through the optical shaft to the subcutaneous tissue, outside-in technique under arthroscopic visual control where a skin incision is made to complete the anterior while watching the video monitor. An operating cannula can now be introduced into the subacromial space from the anterior side using Technique Wissinger rod. The position of into the subacromial space, pass the Wissinger rod the needle may be readjusted several times until through the sheath in a posteroanterior direction. The mandrel is withdrawn from the positioning of the arthroscope and sheath is maintained, the needle. A 1-mm Kirschner wire is introduced through the the anterior side and replaced with a shaver, which positioning needle into the subacromial space. A cannulated dilator is passed along the Kirschner wire into the subacromial space. The operating cannula or Half Pipe is advanced over the final dilator under videoarthroscopic control. The operating cannula or Half Pipe is positioned under videoarthro scopic control. Placement is Exactly the same technique is used as in the anterior governed by the requirements of the operative steps subacromial portal. A portal for the arthroscopic treatment of rotator cuff lesions should be placed at the approximate midpoint of the tear so that subsequent repairs can be performed under optimum conditions. The capsule is in order to understand the anatomical relationships reinforced by the superior and inferior acromioclavicular of this small joint. A fibrocartilaginous pad, called by palpating its surroundings and probing the contour the articular disk, extends from the upper portion of the lines with a needle. It incompletely divides Intra-articular pathology usually requires initial debride the joint cavity into two interconnected compart ment to ensure that the articular surfaces can be ments. The transcutaneous anatomical is placed caudal to the joint using the Wissinger rod landmarks for placing the posterior portal – used for the technique. The bony walls of the joint and the opposing arthroscope – are identified by probing the joint with wall of the joint provide the inferior landmarks. Soft-tissue edema may become severe enough to Because a certain intra-articular and subacromial cause impending respiratory failure that requires irrigation pressure must be maintained at the various postoperative intubation (Fig. The following preventive measures should be helpful in avoiding visualization problems due to bleeding. Lateral decubitus enables us to of the arthroscopic pump until the bleeding stops. Paper presented at the Annual Meeting of the Arthroscopy Association of North America, New Orleans, 1984 9. The precise conformity between between the static and dynamic stabilizers of the the articulating surfaces of the humeral head and shoulder. The repair of an unstable glenohumeral joint must take the glenoid labrum and the capsuloligamentous into account the functional articular anatomy and the complex are the principal stabilizers at the extremes structures responsible for it. Functional abnormalities of shoulder motion in a mechanism called concavity compression11,15. The sagittal section of the anterior of the articulating surfaces and stabilizing structures lead to abnormal laxity of the shoulder joint. This is compression mechanism emphasizes the importance determined in turn by the two articulating surfaces and of an intact rotator cuff. The large humeral head into the glenoid fossa during shoulder motion, the articulates with the smaller glenoid fossa, providing the rotator cuff plays an essential role in the stability of the joint with a large radius of motion. The glenohumeral ligaments act as checkreins to limit the translation and rotation of the humeral head in relation to the glenoid. The posterior labrum shows the greatest variability in its development, and usually it is much less strongly developed than the anterior labrum (Fig. The position of the scapula is also important for gleno humeral stability, but is usually ignored in clinical assessment and treatment planning. Abnormal scapulo thoracic motion may well be a contributing factor to recurrent, refractory shoulder dislocations. The force this is an important point because the degree of of concavity compression is reduced by 50% when the physiologic glenohumeral laxity is a highly individual 11,16 labrum is detached. Glenohumeral instability is considered clinically significant only when symptoms are present. The most active stabilizers of the glenohumeral joint at Various mechanisms are responsible for maintaining the extremes of shoulder motion are the glenohumeral 4–15 ligaments4–18. Functioning as static stabilizers of the joint, anatomical articulation of the glenohumeral joint. One such mechanism is the negative intra-articular these ligaments are particularly important in rotator cuff pressure in the shoulder joint, which is absent in tears where the concavity compression mechanism is no longer operative4–18.

At rst glance medications for ibs purchase isoniazid pills in toronto, this case is simply about a claimant’s need to identify treatment action campaign buy isoniazid on line amex, among a number of defendants symptoms quitting smoking isoniazid 300 mg cheap, the one whose negligence led to his injury symptoms zinc poisoning cheap 300mg isoniazid with visa. But had the Fairchild ruling not been reversed medications in pregnancy order isoniazid 300mg overnight delivery, it would have had repercussions extending beyond the particular problems faced by victims of asbestos-related cancer and would have inuenced any personal injury case in which causation was contested 5 medications that affect heart rate order isoniazid 300 mg. It served as a reminder that McGhee,7 an undoubted victory for the reformers, involved a thinly disguised sleight of hand by ve law lords anxious to prevent a victim of a common occupational disease being denied compensation because of uncertainty in the medical evidence. That celebrated piece of judicial prestidigitation was relied on by the claimant in Page v. Smith,8 which, by granting relief for psychiatric harm arising in a car accident in which no physical injury was caused, was itself something of a milestone. In McGhee, the Law Lords were at pains to point out that theirs was a ‘common sense’11 understanding of causation. A common sense understanding may be all a judge can employ in cases in which science has yet to offer a complete and unchallenged account of the aetiology of a particular condition: the civil courts cannot commission laboratory experiments or epidemiological studies, nor can they suspend a case until someone else does. The various approaches adopted by judges when faced with uncertainty, especially in scientic evidence in negligence cases, have attracted the attention of academic analysts in many countries. In view of the breadth and depth of the related literature,12 and the additions that Fairchild will undoubtedly generate, the aim of any single contribution should be clearly stated. Following an overview of contested causation in personal injury law, this paper considers why the identity of the author of a negligent act might be seen as a special form of uncertainty which cannot be accommodated within the pragmatism of existing common law. Having set the context, the House of Lords ruling is then examined, not in the depth to which pure tort lawyers will feel it merits, but in an attempt to isolate questions 6 J. Negri ‘The European mesothelioma epidemic’ British Journal of Cancer (1999) 79 (3/4) 666–672. Lawyers are denied a comparable choice: the majority of personal injury cases are ones in which res ipsa loquitur applies—an employee’s ngers are amputated in a machine which was not tted with the appropriate guard—and any litigation will revolve around the amount of damages to be paid. In those cases where causation is contested, the dispute most often concerns the relative contributions of tortious and non-tortious acts. Cases involving multiple alleged tortfeasors therefore comprise a sub-category of a minority which is too small to have acquired its own jurisprudence. When faced with the type of problem posed by Fairchild, judges may seek guidance in rules and principles which have evolved from cases which were evidentially (if not legally) simpler. And if judges declare their approach to be based upon ‘common sense’, they must rely upon notions of cause and effect from which all trace of paradox, no matter how appealing it might be to philosophers, has been eradicated. This section of the paper attempts to outline the ‘two-body problem’ of contested causation in personal injury; the following sections then consider the extent to which Fairchild and similar cases require a separate model. Although we tend to use the word ‘cause’ to refer to a single event (the arsonist’s lighting of a match), the event so labelled is usually one of a sufcient set of necessary elements (the availability of combustible material; oxygen in the atmosphere; docility of the security guard; failure of the sprinkler system; late arrival of the re brigade) in a causal path leading to the ‘top event’ (the burning of a factory). Positivism holds that only one of these can be the ‘true’ representation of what actually happened. For the purposes of this paper, the claimant’s task must be seen as involving two14 distinct requirements: he must rst construct a path (either A or B) and then argue that this offers a more likely explanation than either of the paths (labelled C and D in Fig. It is heuristically useful to think of this construction of a causal mechanism as the rst of two elements of the claimant’s task. The second is essentially one of advocacy—persuading the judge (or jury) to accept that this causal scenario, linking loss to negligence, is the most likely representation of a past reality. Reliance upon the balance of probabilities standard is essentially a policy decision which has withstood the test of time. But the judge is not bound by them: he must still consider their signicance, the quality of the procedures by which they were collected and analysed. The extent to which a claimant relies upon hypothetical arguments is, in practice, a matter of choice. But the alternative strategy—establishing that a path, in which N is present, offers the more credible account of the past—has an obvious practical19 advantage. We can never 13 Although Lord Wilberforce suggested, in McGhee (above n 7 at 1012), that the onus should pass to a defendant whose negligence was not disputed. Recently the suggestion appeared attractive to some members of the Australian High Court in Chappel v. But this unequivocal statement of current English law notwithstanding, the burden effectively shifts to a defendant if and when he appeals. And of course, he has every incentive to assume it at rst instance once the claimant’s arguments begin to appear too attractive to the judge. Breach and foreseeability were not in dispute in the great majority of the cases considered in this paper. Kaye ‘The Limits of the Preponderance of the Evidence Standard: Justiably Naked Statistical Evidence and Multiple Causation’ [1982] American Bar Foundation Research Journal 487. Ayer describes as a ‘judgement of credibility’, which he distinguishes from the a priori statements of probability (there is a 50% probability that a true coin will land ‘heads’) and from ‘statistical judgements’ such as ‘the probability that a man will die of lung cancer is increased if he is a heavy smoker’, see Probability and Evidence (1972, Macmillan) p. Cane argues that ‘in a tort action the causal issue always involves a hypothetical (or counterfactual”) question’, the Anatomy of Tort Law (2001, Hart Publishing) at 173. But the forensic process believes that contemporary records and our memory (and that of others) offer us an account of the ‘actual’ past, which is of a different order from our imagining either of the future21 or of hypothetical pasts. The twofold nature of the claimant’s task tends to be obscured in evidentially simple cases: the absence of credible alternative causal paths (capable, in our earlier example, of amputating ngers) and the certain belief in the tortious one (the unguarded machinery) are easily conated. Of the English cases considered in this paper, Wilsher22(described below) perhaps offered, until Fairchild, the clearest articulation of the law on contested causation. But it is also necessary to consider other key cases in which claimants have recovered without having fully satised both parts of their task as set out above. Bonnington23 (1956) Mr Wardlaw contracted silicosis after inhaling dust to which he was constantly exposed in the course of his employment in the foundry at Bonnington (near Edinburgh). Dust arose from two sources: one (N, swing grinders) tortious; the other (X, pneumatic hammers) not. But it was argued that since he could not prove that his condition was caused by the tortious dust (which was physically and chemically indistinguishable from that arising from the other source) then, on the balance of probabilities, he should not recover. Lord Reid (as he did 13 years later when hearing McGhee) rejected this restrictive line of argument (pursued earlier in the minority speech of the Lord President in the Court of Session):. It appears to me that the source of his disease wasthe dust from both sources, and the real question is whether the dust from the swing grinders materially contributed to the disease. But, from the innite set of lawful acts which the defendant might have committed, which do we select to speculate upon Whichever we choose, we must assume that the other necessary elements (the background conditions labelled fi in Fig. This assumption—of stability in the real world—would be vigorously challenged by those chaos theorists who construct systems in which ‘the utter of a buttery’s wing can result in a cyclone’, see D. A worker exposed to ionizing radiation incurred leukaemia for which his employers admitted liability; damages included a provision for the 20 per cent chance of a recurrence (which would be fatal) of the cancer, Molinari v. Applied to harm in a past which we believe we can ‘know’, the p > 50% test results in ‘all or nothing’ damages; but the orthodox test is not applied to subsequent harm arising in a future about which we can only make statements of likelihood. In contrast, a probabilistic dose/effect relationship means that there is no threshold and it is the probability of incurring the condition, not the severity, which increases with exposure. A deterministic or cumulative aetiology (dust N dust X) clearly ts into causal path (A); the widespread acceptance of the cumulative (and detrimental) effect of dust exposure perhaps meant that their Lordships were not obliged to engage in the elegant circumlocutions which a close reading of our next case, McGhee,reveals. McGhee (1972) ForJames McGhee, dust was an ever present, but non-tortious, condition (X) of his employment in a brickworks. The negligent event (N) wasinfact an omission, namely failure to ensure that showers were available to wash off the dust at the end of the working shift. Would Mr McGhee’s dermatitis (H) have arisen even if he had been able to shower at work (N X) or was the consequent delay in removing the offending dust until he reached home another necessary element (N X) in producing this skin disorder According to the dermatologist called by the plaintiff, the contemporary state of medical knowledge was such that ‘he could not say that if the appellant had been able to wash off the dust by showers he would not have contracted the disease’. He was, however, prepared to say that ‘failure to provide showers materially increased the chance, or risk, that dermatitis might set in’. To avoid what was seen as an unsatisfactory outcome, Lord Reid devised a formula which the other Law Lords accepted (albeit with a slightly difference emphasis shown by each judge):. It is based on the practical way in which the ordinary man’s mind works in the every-day affairs of life. From a broad and practical viewpoint I can see no substantial difference between saying that what the respondents did materially increased the risk of injury to the appellant and saying that what the respondents did made a material contribution to his injury. Measures to control dust had been present in statute for many years by then: for example, s. In (provisional29) summary, McGhee requires a conation of ‘a material contribution to. McGhee is important because it placed the concept of risk at the centre of the jurisprudence of causation in personal injury. Lord Reid admitted his reluctance to be bound by ‘logic or philosophy’;30 the House has subsequently shown its reluctance to be unduly bound by McGhee. Ithas, on more than one occasion, applied the orthodox balance of probabilities to nullify the liability of a defendant despite his having negligently increased a claimant’s risk of injury. Hotson31 (1985) Stephen Hotson, when aged 13, fell from a tree and injured his hip. It was only on his second visit to hospital, and after ve days of increasing pain, that the nature and extent of the hip injuries were discovered. The issue was whether the resulting disability could have been avoided had the hip (rather than the knee) been examined on the rst visit to hospital immediately after the fall. The defendant’s expert witness was certain that the negligent examination had made no difference to the nal condition: too many blood vessels in the neck of the femur had already been damaged. The claimant’s witness took the view that there was a somewhat less than 50% chance that lasting damage to the hip was inevitable regardless of prompt diagnosis. It was this contrasting evidence which forced the judge at rst instance to conclude—though ‘not without some difculty’—that the claimant had suffered a 25% loss of chance32 of recovery. Applying McGhee,MrJustice Simon Brown awarded damages calculated at 25% of the full award for such a level of disability. The Court of Appeal upheld this decision but it was soon to be overturned by the House of Lords. Some nine months later, the Court of Appeal upheld an appeal by an alleged victim of a similar instance of medical negligence. But on this occasion, there were some four non tortious causal paths any one of which could have led to the plaintiff’s blindness and the negligent failure (to prevent excessive oxygen supply) represented a fth. In fact, it derived from the despairing pragmatism of Simon Brown, J who, faced with the defendant’s medical witness who was convinced (degree of belief = 100%) that prompt diagnosis made no difference at all and the claimant’s witness who would not advance beyond 50%, resorted to the very dubious expedient of taking the average value of 75%. The expert evidence was empirically based—the claimant’s witness referred to an article which described nine cases of fracture of the epiphysis, of which only four resulted in the avascular necrosis which Hotson suffered. The evidence was more than anecdotal and clearly important but it did not have the compelling weight that would be attached to a major research study which found, let us say, that, of 4000 juveniles falling out of trees, 1000 recovered given prompt diagnosis and treatment. But this line of reasoning was rejected by the House of Lords when considering rst Hotson34 and then Wilsher. Central to the Lords’ decision in Wilsher was Lord Bridge’s identication of the minority speech37 of Browne-Wilkinson, V-C in the Court of Appeal as having established precisely why McGhee did not apply (because belief in the tortious path (A) failed the p > 50% test). A recent case, with evidential circumstances very similar to Hotson, would appear to conrm that the Courts will not compensate loss of chance (of avoiding injury) in medical negligence. They did not have to prove that an alternative and less costly outcome was then certain or even probable (> 50%); they needed only to establish that there existed a ‘substantial chance’ 33 the signicance of the ‘shape’ of risk enhancement is discussed further in Section 4. Once the judge had a degree of belief (p > 50%) that it was meaningful to speak of this ‘substantial chance’ having been lost, then the claimant could recover. The logical structure of Allied Maples becomes equivalent to that of McGhee, Hotson and Wilsher if the lost chance is taken to be as real as the actual economic loss: in other words, if it is treated as a form of harm in itself (H in Fig. Once the judge is prepared to accept the claimant’s account of the creation of the lost chance, recovery becomes possible. The claimant does not have to establish, on the balance of probabilities, that the counterfactual outcome (no loss) would have ensued but for the negligent advice. Several analysts have explored the notion of the negligent imposition of risk of physical injury, regardless of whether actual injury ensues, being actionable in itself. But in McGhee, Lord Salmon argued that the common law did not recognize a distinction between a material increase of risk (of contracting a disease) and material contribution (to causing a disease). Aided by the testimony of an expert witness, their Lordships’ degree of belief in the existence of a material (but unquantied) risk exceeded 50%, recovery for the plaintiff then followed. The Court of Appeal rst in Hotson and later (by a majority) in Wilsher believed it was the intention of the House of Lords to allow recovery for increased risks of less than 50%. In the report of Allied Maples, Hotson and Wilsher(but not McGhee) are listed under cases cited, but the ratio relies entirely upon an application of earlier precedents from the loss of chance tradition, including Chaplin44—a contract case from the Edwardian era involving neither professional nor medical negligence, only the pure (or a priori)45 chance of a lottery. The ‘chance’ that Allied Maples lost was in fact the opportunity to persuade the vendor company to exclude certain liabilities from a contract: the claimant could only speculate on whether the vendor (a third party) would have done so. The ruling in Allied Maples could be interpreted as sparing the claimant the need to prepare a counterfactual argument: once the empirical reality of a past chance is established (p > 50%), he is not required to go further and attach probability estimates to ‘what might have been’. Fairchild and related appeals were argued in terms of ‘risk imposed’ rather than ‘chance lost’. They are cases in personal injury; the key evidence on causation was given by epidemiologists, who constantly referred to asbestos exposure as adding to the risk of mesothelioma. The remaining sections of this paper attempt to set these appeals within the wider context of contested causation, described above, and then to explain why they 42 See J. Around 1500 cases occur annually in the United Kingdom and in only 50 or 60 is there no known history of exposure to asbestos dust. The aetiology remains far from clear: It has been suggested that the initiating cause may be direct or indirect, or a combination of the two. Alternatively, these chemical mediators may stimulate the proliferation of cells, increasing the chances of amalignant cell surviving and proliferating. It is not known whether a single bre or multiple bres triggers the onset of malignancy: each situation is as likely as the other. Epidemiologically informed opinion now sees the development of mesothelioma as a multi-stage process, requiring perhaps as many as seven genetic changes before a normal cell (in the lining of the lungs or the abdomen) becomes malignant. The role which asbestos plays in these various stages remains unknown and it is no less clear whether one or more bres must be present. However, there remains a clear consensus that increased exposure to asbestos will increase the risk of incurring this cancer but, in the event of a sequence of separate periods of exposure, current science cannot identify the one in which the condition was initiated.

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No difference was found in fluid requirement medications qd buy isoniazid visa, haemodynamic parameters or in-hospital complications (Johnson 1992) medicine 027 pill buy isoniazid 300mg lowest price. A randomised study in patients undergoing aortic valve replacement surgery medications after stroke isoniazid 300 mg generic, showed no difference in survival or acid-base abnormalities between the group receiving blood at an Hb of 5 symptoms zoning out purchase isoniazid 300 mg amex. The group with the higher transfusion trigger – the group receiving more blood – suffered significantly more myocardial infarctions and pulmonary oedema treatment neutropenia 300 mg isoniazid visa. Transfusion trigger was defined in this case as the Hb at which erythrocyte transfusions were administered symptoms dengue fever purchase 300 mg isoniazid fast delivery. The 30-day mortality was the same in both groups, but the mortality was significantly lower in a sub-group of younger patients (< 55 years) and less severe disease, if the Hb was maintained at between 4. Various organisations, including the National Institutes of Health, the American College of Physicians, the American Society of Anaesthesiologists, the Canadian Medical Association, the British Committee for Standards in Haematology (Royal College of Surgeons of England, the Royal College of Physicians and the Royal College of Anaesthesists) have published guidelines over the past years concerning the use of erythrocytes. These guidelines assume that a blood transfusion will have few positive effects at an Hb > 6 mmol/L, that a transfusion is often beneficial at an Hb < 4 mmol/L and that – at an Hb between 4 and 6 mmol/L – it depends on patient characteristics whether or not the transfusion is expected to have a positive effect. The so-called 4-5-6 rule was developed based on this information, including important factors for the decision to transfuse: Can the patient compensate for the anaemia (cardiopulmonary status) However, this is a small category, seen in only a few percent of civilian traumas, but is more common in military calamities. The first two definitions of massive blood loss – as mentioned above – often involve less rapid blood loss, which is easier to compensate for. With slower blood loss there is usually no resuscitation situation and a component policy can be implemented based on laboratory values such as Hb, Ht, platelets and clotting parameters. A compensated situation with massive blood loss can occur – for example – peri-operatively or in the intensive care unit. In both the compensated and decompensated situation, with massive blood loss, a coagulopathy due to dilution, use of pro-coagulant factors and activation of anti-coagulant and fibrinolytic factors can further compromise the haemostasis. This dilution coagulopathy” further compromises the blood clotting in the bleeding patient. A critical drop in the number of platelets only becomes evident at a later stage and is reached at a blood loss of more than 2 – 3 times the circulating blood volume (Murray 1995). The extent and time at which these shortages occur depend partly on the rate of blood loss (Koopman-van Gemert 1996, Hirschberg 2003). Research on animals and studies in battle situations have shown that significant tissue trauma – particularly in combination with perfusion abnormalities or low flow situations – triggers the endothelium to increase expression of thrombomodulin. Thrombin is withdrawn from the system and this results in decreased fibrin formation. However, thrombin bound to thrombomodulin can also activate the Thrombin Activated Fibrinolysis Inhibitor, which results in inhibition of fibrinolysis. In addition, a tissue-(plasminogen)activator is released with extended hypotension, acidosis and ischaemia (Lier 2008). Liver function abnormalities, consumption of clotting factors, activated plasmin and fibrin breakdown components contribute to the further deterioration of haemostasis. This phenomenon should be taken into consideration with the infusion of all colloids in large quantities (for example > 1. This is even more applicable if there are pre-existing abnormalities in haemostasis (Levi 2010). The vicious circle that is created in this is also referred to as The bloody vicious circle”. It has been demonstrated that these clotting abnormalities are difficult to correct. Recovery of the hypoperfusion is probably the first point of intervention (Brohi 2009). The hypothermia (decrease in core body temperature < 35 °C) that often occurs in poly trauma patients can perpetuate blood loss by influencing clotting and acidosis. Hypothermia causes a strongly decreased functioning of both the clotting factors and the platelets (Mc Donald 2008, Tieu 2007, Fries 2002). These are the situations in which rapid (within 1 hour, the so-called golden hour”) resuscitation is of great importance for survival. This situation is the most well known in the case of massive uncontrolled blood loss in multi-trauma patients and battle field situations. This also occurs in the case of large gastro-intestinal, obstetric and arterial haemorrhages. The policy is aggressive, pragmatic, pro-active and based on an estimate of the blood loss that has already occurred and is still expected to occur (Geeraedts 2009). Blood Transfusion Guideline, 2011 171 171 the recognition and treatment of patients with uncontrolled blood loss is essential and falls under shock/resuscitation protocols. The European guideline on this subject (Rossaint 2010) is a usable example of this. The haemodynamic reaction to intravenous filling is also an indication for the existing deficit in circulating volume. Laboratory values usually lag significantly behind the rapidly changing condition in the case of persistent bleeding. However, laboratory tests should be performed as soon as possible, even if only to have the initial data to allow for better estimates of the situation. The base excess and the lactate level are important values used to estimate the extent of hypoperfusion and the degree of shock. The infusion and transfusion policy in the initial phase is based on an estimate of the circulating volume lost and still expected to be lost until the bleeding has been stopped or can be controlled. This phase should be implemented as soon as possible after the bleeding or the trauma occurs and usually takes place at the site where the trauma occurred, during transport to the hospital, in the Emergency Department or early on during corrective surgery. Optimisation of the circulating volume and the haemostasis – so that the bleeding can be stopped most effectively – are key points in this. In unstable poly-trauma patients with massive blood loss, stopping the bleeding – often from various locations – very quickly is foremost (Kaasjager 2001). In order to prevent loss of time, the system of damage control” surgery was developed for this (Poortman 2000, Martin 1997). A recent European guideline (Rossaint 2010) emphasises the particular importance of a multi disciplinary approach for the best possible resuscitation and damage control” surgery, now called damage control resuscitation”. The aim of the resuscitation is to optimise the circulation blood volume and oxygen transport further. Although insufficiently evidence-based, accepting a permissive hypotension” due to restrictive fluid infusion is an accepted strategy. This can decrease blood loss in the event of massive blood loss (Fowler 2002, McIntyre 2002, Hiippala 1998, Bickel 1994, Brimacombe 1994/1993, Crawford 1991, Johansen 1991). The oxygen transport and haemostasis should also be optimised (Fries 2002, Corazza 2000, Hiippala 1998). Hypothermia, clotting abnormalities and acidosis (lethal triad) negatively affect the prognosis (Eddy 2000). Level 3 C Kaasjager 2001, Martin 1997 D Poortman 2000 In poly-trauma patients (decompensated situation), it is important that the resuscitation is started soon after the accident. B Beekley 2008 A multi-disciplinary approach is deemed important for the best possible resuscitation and damage control surgery, now called damage control Level 3 resuscitation”. C Rossaint 2010 It is likely that the acceptance of ‘permissive hypotension’ due to restrictive fluid infusion can reduce the blood loss in the case of massive blood loss in a decompensated situation. Level 3 C McIntyre 2002, Bickel 1994, Johansen 1991 D Fowler 2002, Hiippala 1998, Brimacombe 1994, 1993, Crawford 1991 In poly-trauma patients (decompensated situation), it is important to optimise the oxygen transport and haemostasis and to correct any Level 3 hypothermia and acidosis. In addition to platelets and plasma, erythrocyte transfusions also play an important haemostatic role. Blood Transfusion Guideline, 2011 173 173 A number of studies have appeared in the last few years that concluded that – in addition to the basis measures of resuscitation – a transfusion policy with set ratios between erythrocytes/plasma/platelets increases survival. There are indications that this is due to prevention and/or correction of the dilution coagulopathy (Beekley 2008, Gonzalez 2007, Hardy 2004, Holcomb 2008, Johansson 2009, Johansson 2010). In the study by Johansson (2009), for example, the following transfusion schedule was used: 5 erythrocytes units: 5 plasma units: 2 platelet units (from 5 donors) in bleeding patients who received > 10 erythrocyte units/24 hours. This strategy of administering several components is usually referred to as multi component transfusions or as the administration of transfusion packages (Madjdpour 2006, Hirschberg 2008, Holcomb 2008). Apart from the logical reasoning that this strategy proactively prevents haemostatic dilution in massively bleeding patients, these studies do not clearly show which volume of fluid/colloids or erythrocyte transfusion should be started with. These ratios are based on retrospective studies (Borgman 2007, Ho 2005, Murad 2010, Roback 2010, Johansson 2010, Saltzherr 2011) where – as mentioned – large amounts of erythrocytes and fluids have already been administered. Studies of battle field situations also use fresh full blood transfusions or erythrocyte transfusion < 15 days old. The improved survival due to a transfusion policy with a relatively high plasma-erythrocyte ratio has also not been confirmed in all situations of massive blood loss (Scalea 2008, Dirks 2010). Finally, there is discussion about whether the association of a high ratio of plasma-erythrocytes with improved survival is the result of improved survival (bias) instead of the other way around (Snyder 2009). Prospective randomised research is desirable before definitive exact recommendations can be made (Johansson 2010). Level 3 C Hirschberg 2008, Johansson 2009,2010, Holcomb 2008 Multi-component transfusions in patients with massive blood loss are associated with improved survival. Level 3 C Hirschberg 2008, Holcomb 2008, Murad 2010, Roback 2010, Snyder 2009 A transfusion policy with set ratios of erythrocytes/plasma and platelets appears to increase survival in the case of decompensated massive blood loss when combined with the basic measures of resuscitation. Level 3 C Johansson 2009, Murad 2010, Roback 2010, Johansson 2010, Saltzherr 2011 174 Blood Transfusion Guideline, 2011 There are indications that transfusion of erythrocytes and plasma units in equal quantities, together with approximately one third of that volume in platelet units (concentrate from 5 donors), results in improved survival. However, it is not yet clear what the optimum ratio is and when is the best Level 3 time to start a multi-component policy for massive blood loss. C Johansson 2009 en 2010, Beekley 2008, Holcomb 2007, Gonzalez 2007; Hardy 2004, Saltzherr 2011 5. If a normovolemic (and oxygenated) state can be maintained, the patient will not go into shock and this is called a compensated situation. The lowest acceptable limit for acute anaemia due to blood loss has not been determined in humans, because this depends on the speed of blood loss and the physiological capacity and the therapeutic measures to accommodate for the blood loss. The Hb value is only reliable once the circulating blood volume has been restored. If the blood loss has been controlled by optimising haemostasis, the erythrocyte mediated oxygen transport becomes the major factor in the policy. However, it is not yet possible to measure accurately the transfusion-related improvement of low oxygen transport and tissue oxygenation. As the local (from organ to organ) oxygen extraction at a tissue level (particularly in the case of sepsis and ischaemic multiple organ failure) can differ from the systemic oxygen extraction, it may be necessary in future to consider basing the decision to transfuse and the monitoring of the efficacy on oxygenation measured in target organs (Stowell 2009). There are data available about the critical limits for tissue oxygenation in experiments with acute normovolemic haemodilution; this is a compensated situation with corrected circulating volume (normovolemia), good oxygenation and normothermia. Based on these data, there are indications that the tissue oxygenation generally remains adequate down to an Hb of 3 – 5 mmol/L. This applies to these circumstances in healthy volunteers, for both the heart function and the brain function (Weiskopf 1998). In the case of acute blood loss – with another dilution step to follow – it appears to be better not to allow the Hb to drop to 3 mmol/L. This concentration is mentioned in the literature as the limit below which cerebral function abnormalities occur (Madjdpour 2006). A prerequisite is that normovolemia, normothermia and oxygen Level 2 supply are maintained. B Weiskopf 1998, Madjdpour 2006 C Madjdpour 2006 There are indications that the Hb level is reliable as soon as the circulatory blood volume has been restored. Level 3 C Elizalde 1997, Wiesen 1994 There are indications that cerebral function abnormalities occur at an Hb level lower than 3 mmol/L. Level 3 C Madjdpour 2006 Partly due to the limited value of the Hb measurement, particularly in the case of persistent bleeding, there is little evidence to indicate the Hb concentration at which erythrocytes need to be transfused. In a bleeding patient – taking into consideration the delay in determination – a measured fibrinogen of 1. It is becoming increasingly accepted that – in the case of a large loss of circulating volume – the coagulopathy (due to loss and dilution) can be severe and in particular fibrinogen decreases to critical levels sooner than other clotting factors (Chowdhurry 2004, Corazza 2000, Murray 1995, Hiipala 1995). Based on a mathematical model, it appears that fibrinogen – particularly 176 Blood Transfusion Guideline, 2011 if the pre-dilution initial value is on the low side of normal – is the first factor to fall below the critical value for normal haemostasis in the case of normovolemic haemodilution (Singbartl 2003). Of course, medicines that inhibit haemostasis – such as heparin, coumarins and platelet inhibitors – should be stopped (temporarily) or reduced. Administration of 30 – 50 mg/kg fibrinogen concentrate appears to be Level 3 associated with improved outcome. C Fenger-Eriksen 2009, 2008, Rossaint 2010 Fibrinogen preparations are usually not necessary with a multi-component transfusion policy (so-called transfusion packages with set ratios erythrocytes/plasma/platelets), provided these are used aggressively and in a timely manner. However, the advice is increasingly to provide extra and faster compensation of the clotting-dependent haemostasis if surgical haemostasis cannot be achieved in the short term. The use of anti-fibrinolytics (tranexamic acid) appears to have a positive effect on mortality due to massive blood loss with severe trauma. However, confirmation of this in a setting more similar to that in the Netherlands is desirable before a definitive recommendation of tranexamic acid in trauma patients. Research to confirm this – in a setting more similar to the Dutch Level 2 situation – is recommended, focusing on thrombotic side effects. It should be noted that directing the transfusion policy based on thrombo elastography/elastometry has never been validated. It is crucially important to have a good agreement with the laboratory about the communication and the procedure to be followed for massive blood loss. Citrate intoxication In the case of massive plasma transfusion, citrate intoxication can occur, which is characterised by hypotension, increase in end ventricular diastolic pressure and increase in central venous pressure. In patients with liver failure, citrate is metabolised more slowly and the risk of hypocalcaemia is greater. Hyperkalaemia Potassium release from erythrocytes takes place during storage which raises the potassium concentration in the storage solution; this should be taken into consideration in the case of massive transfusions, particularly in patients with renal insufficiency. In the case of severe continuing blood loss, consider rapid ‘damage control’ surgery and/or a radiological intervention (see also Chapter 8. Correct haemostasis with multi-component transfusions in ratios as listed under recommendation 7.

When a Progress Board is to be convened because of an Evaluation Board or Honor Board recommendation or due to an issue concerning the school’s Criteria for Academic Review and Advancement symptoms 6 days post iui purchase generic isoniazid on line, the Associate Dean for Student Affairs shall notify the student at minimum by email in time to provide at least 10 working days notice before the date on which a board is convened 10 medications purchase 300mg isoniazid fast delivery. The Associate Dean for Student Affairs will inform the membership of the Progress Board of the need to meet and will assist in arranging meetings but will not participate in deliberations or voting medicine effects proven 300 mg isoniazid. A student must be invited but is not required to attend any Progress Board meeting at which an adverse recommendation is being considered symptoms after embryo transfer buy generic isoniazid 300mg online. The student must be notified by the Associate Dean for Student Affairs in writing by hard copy or email that the Progress Board is meeting to consider a case in which the student is involved at least 10 days before the meeting symptoms brain tumor cheap isoniazid 300 mg fast delivery. If the student wishes to meet with the Board treatment innovations cheap isoniazid 300mg with visa, the student’s request must be given in writing to the Associate Dean for Student Affairs at least two working days prior to the Boards’ meeting. A student who elects to meet with the Progress Board may bring an advocate into the hearing room with him or her. In a case in which no criminal charges are pending, the advocate can be any member of the university community. However, no parties shall be represented by legal counsel (this restriction includes faculty members and students other than the accused student who also have formal legal training). The role of the advocate is to assist the student in presenting his/her side of the case as effectively as possible. If criminal charges are pending, the student may bring an attorney as an advocate and the University may also choose to be represented by legal counsel. The Basic Science Academic Evaluation Board meets approximately monthly during the academic year; the Clinical Science Academic Evaluation Board convenes approximately monthly with executive meetings being held as necessary. It is the responsibility of each Board to review a student’s entire record, taking into consideration the overall pattern and quality of a student’s academic performance. It should be emphasized that the recommendations of the Boards and actions of the Progress Board, ranging from unqualified promotion to dismissal, are based upon assessments of academic and technical competence and upon qualitative, ethical and behavioral criteria. Any recommendation made by either Academic Evaluation Board that are considered an adverse recommendation; including requiring a student to (1) repeat a whole semester or an entire year; (2) enter a less than full-time or other program which will delay the student’s time of graduation, (3) take a leave of absence at the initiative of the Board rather than of the student, or (4) be dismissed must be presented to the Progress Board. Course coordinators for each course will establish prerequisites for progression to that course or block of a course. Students who have satisfied the prerequisites will be permitted to progress to that course or course block. Students meeting these requirements are eligible for advancement unless additional information brought to the attention of the Board (e. The change in student status will be effective from the date at which the student begins the action which will extend the program. Program extension may include a period of academic leave, either to bring the student’s schedule back into synchrony with the curriculum or to require or allow specific support activities (e. Prior to the core clinical experience, the student is assigned by computer match to thematic sections. Similarly, an approved subinternship and a clerkship in Neurology are scheduled during the fourth/Advanced Studies year/s, in addition to *electives chosen by the student. All remediation efforts must receive prior approval of the appropriate Academic Evaluation Board. Students attempting a remediation by course repeat are not eligible to take the remediation exam following this course repeat. If a student fails to obtain a grade higher than the initial grade by repetition of the course, the original grade will stand. A course may not downgrade a post-remediation rating as a penalty for a previous performance. Dismissal the Progress Board may recommend to the Dean of the Medical School that a student be dismissed. Background the Basic Science Academic Evaluation Board and the Clinical Science Academic Evaluation Board are charged with reviewing the progress of all medical students. From time to time, these Boards find it necessary to make recommendations to the Progress Board which may recommend to the Dean of the Medical School an extended period of study or otherwise affect a student’s progress. Students are encouraged to try all other routes for resolving differences before resorting to the filing of a formal appeal. Students should seek the counsel and help of the Office of Student Affairs and consider such an appeal only after all alternative routes have been explored. An appeal alleges a mistake in the facts relied upon for the decision or that the facts support different action by the Progress Board. The Academic Evaluation Boards are the bodies charged with evaluation of the progress of students and with making recommendations either for promotion, for some remedial program or for dismissal. The Basic Science Academic Evaluation Board monitors progress in the first two (Pre-clerkship) years and the Clinical Science Academic Evaluation Board monitors the last two (Clerkship) years. An adverse recommendation is a recommendation of either the Basic Science Academic Evaluation Board or the Clinical Science Academic Evaluation Board to the Progress Board to have the student (1) repeat a whole semester or an entire year; (2) enter a less than full-time or other program which will delay the student’s time of graduation, (3) take a leave of absence at the initiative of the Board rather than of the student, or (4) be dismissed. This document addresses appeals filed by students in regard to promotion and dismissal or any adverse decisions. A grade which does not affect promotion or retention may not be appealed beyond the Chair of the Department. Appeals related to issues of Affirmative Action are handled by a specific procedure for such problems (cf. The appeal must be in writing and state (i) the factual and/or procedural basis for the appeal and, (ii) the resolution the student seeks/ Senior Faculty Member. A Senior Faculty Member is a member of the faculty at the rank of Associate or Full Professor and participating regularly and significantly in the formal medical curriculum. The Standing Academic Appeal Committee is a standing committee of the faculty appointed to aid the Dean in evaluation of appeals. The committee shall consist of four senior faculty members, two from basic science departments and two from clinical departments. No member of an Academic Evaluation Board can serve concurrently on the Standing Academic Appeal Committee. The committee shall choose a Chair within as expeditious a time frame as practical, usually within ten working days of its constitution. In the event that the committee cannot agree on a Chair, the Dean shall select one from the committee. In the event of a conflict of interest on the part of a member of the Standing Academic Appeal Committee when issues relating to a specific student arise or in the event that a committee member will not be available given the constraints of time associated with prompt evaluation of an appeal, the Dean shall appoint a substitute. Where practical, the substitute shall be chosen so as to preserve the existing balance of the committee. The Ad Hoc Academic Appeal Committee is a committee constituted to aid the Dean in decisions involving non-procedural issues which may result in dismissal. It consists of the members of the Standing Academic Appeal Committee supplemented by a senior faculty member appointed by the Dean from a list of three senior faculty members submitted by the student as part of the written document outlining the appeal. The Dean shall screen this appointee for a possible conflict of interest in issues involving the student in question and the Dean shall confirm that the appointee will be available as required for expeditious evaluation of the appeal. The Chair of the Standing Academic Appeal Committee shall serve as Chair of the Ad Hoc Academic Appeal Committee. Process for an Appeal In order to file any appeal, the student must produce some evidence of error beyond the student’s simple assertion that the Grade Granting Unit or Board was wrong. For example, if a student disagrees with the grade assigned by a Grade Granting Unit, the student should discuss the issue with the faculty coordinator of the relevant course, clerkship or elective and request a reconsideration by the grading committee if that option is offered by the coordinator. In the event of unsatisfactory resolution of the issue by the grade granting unit, the student has the option to request a reconsideration by the Chair of the relevant department or departments for interdepartmental courses. The appeal to the Chair of the department is made by writing a letter to the Chair outlining the reasons for disagreeing with the grade. The Chair will convene a small group of faculty, not including the course coordinators, who will review the grade and may interview the student and the course coordinators in coming to a determination. Once a decision has been made the Chair will inform the student of the outcome by letter. A copy of that letter will also be sent to the Associate Dean of Student Affairs who will inform the appropriate Academic Board. An appeal to the Dean of the Medical School/Academic Appeal Committee may be made only if the grade has an impact on promotion or dismissal. For example if a grade results in a requirement for repeating a course or other action resulting in a requirement for program extension, it may be appealed in this way. Throughout the process of the appeal, the student will receive information about the progress of the appeal from the office of the Associate Dean for Student Affairs and/or directly from the office or committee reviewing the appeal. If the recommendation of the Progress Board involves the student entering a less than full-time program or repetition of a whole semester or an entire year, the recommendation must be implemented within a reasonable period of time so that the student will be able to take the courses while they are still available. Procedure I is intended to be as expeditious as practical consonant with a fair and reliable evaluation. A student wishing to file an appeal related to such a decision must do so in writing to the Dean of the School of Medicine within 10 working days of receipt of notification of the decision of the Progress Board. The Dean of the School of Medicine will refer it to the Standing Academic Appeal Committee for review. This Committee shall evaluate the appeal and report its finding to the student, the Progress Board, and the Dean, within as expeditious a time frame as practical, consonant with a fair and reliable evaluation, usually within 20 working days. A majority vote of the Standing Academic Appeal Committee is required to recommend reversal or revision of a decision of the Progress Board. If the Committee vote results in a tie, the Progress Board’s decision shall be upheld. In the event that the Committee disagrees with the Progress Board, the Committee’s report shall include a recommendation for correction. The Dean shall review this recommendation and forward it (with any appropriate modifications) within as expeditious a time frame as practical, consonant with a fair and reliable evaluation, usually within 10 working days of receipt to the Progress Board which shall follow the Dean’s directions to remedy the appeal. When the appeal relates to a recommendation of the Progress Board for dismissal, the student must notify the Associate Dean for student Affairs of the intent to file an appeal. This must be done in writing within 10 working days of receipt of the notification of the decision of the Progress Board. The student’s notification of intent to file an appeal may include a list of three senior faculty members from which the Dean of the Medical School may choose the ad hoc member of the Ad Hoc Academic Appeal Committee. If no list is submitted, the Dean shall appoint an ad hoc member of his/ her choosing. Within 20 working days of receipt of the decision of the Progress Board, the student must file the written appeal. The Dean of the School of Medicine shall review this document and take one of the following three actions. In addition, the Ad Hoc Academic Appeal Committee shall make a reasonable effort to include participation of all persons it, the student, the Dean, or any member of the faculty shall deem appropriate and necessary for a full evaluation of the case. In the case of a dismissal on the basis of academic performance, allegations of academic dishonesty or disciplinary action in which no criminal charges are pending, no parties shall be represented by legal counsel (this restriction includes faculty members who also have formal legal training). In the case of dismissal on the basis of academic dishonesty or disciplinary action, a student may submit a written statement drafted by an attorney and that statement will be considered by the Ad Hoc Academic Appeals Committee before a final decision is issued. A student subject to dismissal who faces criminal charges arising from the same facts shall be permitted to select as his or her mentor an attorney, without regard to whether the attorney is a member of the campus community. This right to have an attorney present (at the student’s expense) will also apply when, in the judgment of the Ad Hoc Academic Appeals Committee, it appears likely that such charges will be filed. The Chair of the Ad Hoc Academic Appeal Committee shall have the right to limit witnesses and testimony to that which the Chair deems relevant to the issues at hand. The Chair may also meet informally with any parties to the dispute to identify points on which both sides agree and thereby streamline the hearing itself. The student shall have the right to hear all testimony and to see all evidence introduced as part of the review process (however, in the event that the evidence should contain information relevant to other students, their identities shall not be disclosed to the student). The student shall be allowed five working days to prepare and submit a written rebuttal of any testimony presented at the hearing. After all the testimony and evidence have been presented, the Ad Hoc Academic Appeal Committee shall meet to evaluate the issues raised in the appeal and the hearing. The Ad Hoc Academic Appeal Committee shall render its recommendations to the Dean of the Medical School within as expeditious a time frame as practical, consonant with a fair and reliable evaluation, usually within twenty working days. In the event that the Ad Hoc Academic Appeal Committee disagrees with the original decision, the Dean shall ask the Progress Board to reconsider its decision. The Progress Board shall respond to the Dean within five working days of its next meeting. The Dean shall then evaluate the case, reviewing all the written evidence in the case and interviewing the student and the student’s advocate (if the student so desires). In particular, in the event of a disagreement between the Progress Board and the Ad Hoc Academic Appeal Committee, the Dean shall make the final evaluation of the appeal and, if it is indicated, effect a mechanism for redress. In the event that the Ad Hoc Academic Appeal Committee supports the original decision, that decision shall be final. However, with the exception of the time limit for filing an appeal, all time limits may be extended at the discretion of the Dean of the Medical School. The time limit for filing an appeal may be extended only in those instances where the Dean finds that there are extreme extenuating circumstances justifying such an extension and that the appeal process will not be unduly burdened as a result. Advanced Standing Given the integrated model for our courses and curricular framework, requests for advanced standing will be considered on a case by case basis. Under the oversight of the Associate Dean for Undergraduate Medical Education, requests for advanced standing in a given course will be reviewed by the respective curriculum committee and subject to approval by the designated course co-leaders. Requests for advanced standing should be directed to the Associate Dean for Undergraduate Medical Education. Faculty and Student Notifications: the credit hour assignments will be included in the appropriate student handbook and they will be provided to the Office of Faculty Affairs for inclusion in the orientation program for new faculty. It will also be presented at relevant curriculum committee meetings to ensure faculty awareness. School of Medicine (SoM) Course Credit Hour Assignments Existing Curriculum: Each grade-granting course is assigned credits based on the following process, which builds on standard educational benchmarking and local expertise in curriculum development and expectations for clinical work: • Year 1-2 foundational curricula: approximately 15 classroom. New Course Development: Newly approved courses will apply this metric to confirm appropriate credit.

Tighten your knee on surgical leg and slowly lift your leg to the level of the bent knee administering medications 6th edition generic 300mg isoniazid. Conditioning/Strengthening Exercises Move shoulders forward in a circular motion for a count of 10 medications made from plants generic isoniazid 300mg on-line. The front passenger car seat should be pushed all the way back before you enter the car treatment pink eye buy isoniazid online. They do not establish a standard of medical care and have not been tested for all potential applications medications for bipolar order 300mg isoniazid mastercard. These Measures and specifications are provided as is” without warranty of any kind treatment 001 - b buy isoniazid mastercard. Limited propriety coding is contained in the Measure specifications for convenience symptoms uterine fibroids purchase isoniazid 300 mg with visa. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Users of the Measures shall not have the right to alter, enhance, or otherwise modify the Measures. Several of the total knee replacement measures have been adopted for use with patients undergoing a hip arthroplasty. This project utilized the expertise of practicing orthopaedic surgeons and other clinicians to create explicit, valid, and feasible quality measures that can be used to monitor and improve the quality of orthopaedic care. The measures evaluate outcomes and appropriate preoperative, intraoperative, postoperative care which are critical to improving patient function and quality of life. The report showed a wide variation (between $11,327 and5 $73,987) in the cost of hip arthroplasty across the nation. Three measures address patient outcomes and three measures address processes of care. These measures are meant to be used for performance at the individual physician level. Replacement arthroplasties are effective and cost-effective for patients with significant symptoms, and/or functional limitations associated with a reduced health-related quality of life, despite conservative therapy. No threshold was determined (mm/hr) C-Reactive Protein (mg/L) 100 Synovial White Blood Cell Count 10,000 (cells/l) Synovial Polymorphonuclear (%) 90 Leukocyte Esterase + Or ++ > 5 neutrophils per high power field in 5 high power fields Histological Analysis of Tissue ( 400) International Consensus Group on Periprosthetic Joint Infection 20149 Measure Importance Rationale A study based on data from the California Joint Registry performed by SooHoo and colleagues found a 90-day complication rate of 3. Justification Harmonization Harmonization with existing measures under development was attempted. Hip Survey includes 6 questions (2 questions related to pain and 4 questions related to function). Replacement arthroplasties are effective and cost-effective for patients with significant symptoms, and/or functional limitations associated with a reduced health-related quality of life, despite conservative therapy. Most studies reported on post operative outcomes up to 6 or 12 months but there were some data on clinical outcomes up to 7 years following surgery. All studies reported substantial improvements in pain and physical functioning but the effects on mental health and social functioning were more variable. Pain scores improved more quickly and more dramatically than physical functional outcomes with maximal improvements in the first 3 – 6 months. National Quality Person and Caregiver-Centered Experience Outcomes Strategy Domain Exception this measure has two denominator exceptions. Replacement arthroplasties are effective and cost-effective for patients with significant symptoms, and/or functional limitations associated with a reduced health-related quality of life, despite conservative therapy. For patients with severe disability, the patient and surgeon may decide after a thorough review of conservative options that the optimal treatment is to proceed with the operative intervention. In a study conducted by Bozic and others, patients who were considered appropriate for hip or knee replacement were provided either a shared decision making intervention or normal care. The patients in the intervention group reached an informed decision 58 percent of the time during the first visit with the surgeon compared to the control group (33 percent). The decision and communication materials helped both the patients and the orthopedic surgeons. Justification 11 American Association of Hip and Knee Surgeons Primary Total Hip Arthroplasty Harmonization Harmonization with existing measures was not applicable to this measure. In the asymptomatic patient, a more extensive assessment of history and physical is warranted in those individuals 50 years of age or older, because the evidence related to the determination of cardiac risk factors and derivation of a Revised Cardiac Risk Index occurred in this population. Preoperative cardiac evaluation must therefore be carefully tailored to the circumstances that have prompted the evaluation and to the nature of the surgical illness. A population-based study of all Olmstead County, Minnesota, patients undergoing a total hip or knee arthroplasty from 1994 2008, reported that patients undergoing a total hip arthroplasty with a previous history of a cardiac event or a thromboembolic event were associated with an increased risk of a 90-day cardiac event following surgery. Justification Harmonization Harmonization with existing measures was not applicable to this measure. The number of patients undergoing a revision total hip replacement is more than 40,000 annually at a direct cost of over $1 billion. The initial operative report should contain the necessary information which will ultimately help the future treating physician who performs the revision surgery. National Quality Patient Safety Strategy Domain Exception this measure has no exceptions. Justification Harmonization Harmonization with existing measures was not applicable to this measure. Development of quality of care indicators for patients undergoing total hip or total knee replacement. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Hospitalization for total hip replacements among inpatients aged 45 and over: United States, 2000-2010. Medicare lack of price transparency may hamper hospitals’ ability to be prudent purchasers of implantable medical devices. The health of America: a study of cost variations for knee and hip replacement surgeries in the U. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030 J Bone Joint Surg Am 2007;89(4):780–5. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. Health-related quality of life in total hip and total knee arthroplasty: a qualitative and systematic review of the literature. Responsiveness in patient reported outcome measures in total joint arthroplasty patients. Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized trial. Cardiac and thromboembolic complications and mortality in patients undergoing total hip and total knee arthroplasty. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement a nationwide cohort study. Knee implants consist of (1) a metal piece attached to the end of your thigh bone, (2) a metal and plastic or all-plastic piece attached to the top of your lower leg bone and (3) a plastic piece attached to your kneecap. The surgical approach to knee replacement surgery requires that appropriate healing is allowed to take place. There are certain milestones during rehabilitation that require that the patient be an active participant in rehabilitation to help ensure the best outcome. Wean from walker to crutches to cane only when patient can make transition without onset of gait deviation. Modalities Cold pack or ice pack for 10-15 minutes 3x/day to manage pain, inflammation, and swelling Criteria for progression to next phase: Minimal pain and inflammation Pt ambulates with assistive device without pain or deviation Independent with current daily home exercise regimen Progression to driving: must be off all narcotic analgesics in order to concentrate on driving tasks. Patients being discharged home passive knee extension at 0 promote knee extension prioritized. Increase independence with Encourage all normal phases of gait pattern using appropriate device. Once the failed components, cement, and useless weak bone have been removed from the knee, a gaping hole confronts the surgeon. The problems of stability, mobility, xation, and the reconstruction of bone defects as well as restoration of an anatomic joint line all cry out for attention at once. One thing is certain—an organized approach is essential or the reconstruction is doomed to failure (Fig. This chapter proposes three steps to the reconstruction of any knee regardless of the original cause of failure. The surgeon must (1) reestablish the tibial platform, (2) stabilize the knee in exion, and (3) stabilize the knee in extension. These steps have been described previously1–3 and are based upon the principles of knee arthroplasty surgery that were developed for the total condylar knee prosthesis by John Insall, Chit Ranawat, and Peter Walker at the Hospital for Special Surgery in New York in the early 1970s. Faithful adherence to the proposed sequence of steps, building one stage upon the other leads to a successful revision knee arthroplasty (Table 8. Although contemporary instruments have enabled every surgeon to produce good primary knee arthroplasties, they rely on bone for reference. Working with strong concepts and trial components, the surgeon will be able to understand the vagaries of lost, plastically deformed, overly tight, and unreleased ligaments. This chapter does not deal with the diagnosis of a failed knee arthroplasty nor with the techniques for the removal of compo nents from a failed knee. It must be emphasized, however, that no revision surgery should be attempted until an accurate mechanical explanation for the failure has been established. Revision of the inexplicably painful knee arthroplasty will yield miserable results. The tibial articular surface is involved with knee function, irrespective of joint position. Whereas the distal femur bears load only in full extension and the posterior femur only in exion, the tibia is con stantly part of the articulation. Do not be concerned about the articular surface at this stage, that will come later. Although good-quality host bone is respected, any tibial cutting guide can be used to square up” the surface by removing obviously weak and dispensable tissue. Any bone cut made now must not sacrice good bone in an effort to eliminate a bone defect. In many revision knee arthroplasties, medullary xation will be required to enhance xation. If so, open the medullary canal and conrm the measurements of endosteal diameter made on pre operative radiographs, using hand reamers. Once seated in the medullary canal, the tibial trial denes the defective bone that will require re-construction. If the intramedullary rod, tted into the canal, is not parallel to the long axis of the tibia, the rod may be too wide for the asymmetric canal and either a narrower rod or one that is offset may be required. There are several complex classication systems for describing bone defects at revision knee surgery. The simplest approach, in the course of a demanding surgery, will be the most helpful. Defects that are contained and have a rim of bone to hold bone graft, can be lled with particulate graft, be it autograft from the knee, ground up fresh-frozen bone, or freeze-dried allograft bone chips. Noncontained defects, as seen when a tibial component has sub sided into varus, will most easily be dealt with by modular wedges or blocks. Combined contained and noncontained defects exist and respond well to a combined approach—the contained area is lled with graft and the noncontained area is reconstructed with an augment on top of the graft (Table 8. Massive defects that offer virtually no host bone on which to seat any of the component will usually require reconstruc tion with structural allograft. These unusual situations should still be reconstructed following the three steps that are described here. A simple approach to bone defects Bone defect Solution Contained Particulate bone graft Noncontained Modular wedge or block Massive Structural allograft Tibial defects can be reconstructed at this stage and the tibial component even cemented into place to save time. This is because the tibial platform does not affect how we reestablish alignment, stability, and motion in the knee. Tension and laxity in exion and extension are manipulated with the femoral component. Nonetheless, in the interest of keeping most of our options open, it is best to leave the trial tibia in place, noting the type of bone defect if any and how we plan to recon struct it when we implant the nal components. It is a common and deadly error to measure existing bone and simply t the corresponding femoral component to it. In almost every case, this will lead to the selection of a femoral com ponent that is too small and an arthroplasty that is unstable in exion or one in which excessive distal femoral bone must be resected to accommodate an unduly thick articular polyethylene. Undue resection of distal femur results in an unacceptable proxi mal migration of the joint line. Ignore the residual bone on the distal femur in this step and visualize the normal bone that was present before any surgery had been performed. Use the size of the failed component, and lateral radiographs of the contralateral knee, if unoperated, to estimate the size of the revision femoral component. The nal choice of revision femoral component size will depend upon the an teroposterior dimension that is necessary to stabilize the knee in exion. The revision femoral component size will be determined not by residual bone, so much as by the soft tissues, specically the collateral ligaments. Stability in exion is determined not only by the size, but also by the anteroposterior location of the femoral component. They exist to ll in bone defects and consequently to stabilize the knee in exion by enabling the surgeon to select an appropriately large femoral component. In the presence of defective bone, due either to defects or soft quality, enhance xation with medullary stems. These will inu ence the position of the femoral component and accordingly the stability of the knee in exion.

Additional information:

• Indinavir
• Ritonavir

References:

• https://dev.org.es/exploration/purchase-proscar/
• https://www.scbwi.org/wp-content/uploads/2013/09/SCBWI_The-Book_7-17.pdf
• https://newheartvalve.com/wp-content/uploads/2017/04/Aortic-Stenosis-Fact-Sheet.pdf