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His study also shows by indirection the power and allure of the Hippocratic tra- dition buy cheap coumadin 5mg on-line, which entrances people with a purported moral tradition over time discount coumadin 2mg visa, without substantiating that such a tradition exists coumadin 2mg with mastercard. Indeed, it is interesting that Miles does not successfully show how the ethical principles in the Oath (and here again one must note that the Oath s sense of ethical principles is surely not ours) and the symbolic force of the Oath can direct the contem- porary project of reclaiming a sense of medical professionalism. W hat he does show is that there is m uch re-im aging of w hat the Hippocratic O ath, tradition, and ethos should mean, not what they actually meant. These brief reflections on the Oath and Stephen Miles study of that Oath disclose major challenges in recapturing a coherent sense of medical professional identity and medical professionalism. It would be well to recall that the Oath is in fact puzzling because of the numerous levels of concerns it compasses beyond the ethical. It directs itself to religious concerns, to an esoteric sense of esprit-de-corps, and to special obligations binding students to teachers (and by extension medical professionals to each other). Medical professionalism may be grounded in much more than the supposed universal moral commitments that most contemporary scholars attempt to read back into the Oath. It indeed compasses moral claims that could be understood in universal terms, but it is inevitably a particularistic document that aims at creating a particular sense of identity for the Hippo- cratic practitioners. One must take much more seriously the complexity of the Oath and the complexity of medical professionalism. All of this substantiates the crucial need to take the philosophy of med- icine seriously. Such a philosophy of medicine should turn to developing a medical-moral philosophy that can place or locate bioethics. An effort to revisit the philosophy of medicine seems necessary in the light to the cur- rent condition of bioethical reflection (e. First, contemporary medicine must think through what is involved in professional commitments, what is The Hippocratic Oath and Contem porary Medicine 123 necessary for professional identity, and what internal values should be nur- tured by the profession. Second this assessment may draw strength from a critical appreciation of the extent to which, if any, contemporary medical professionalism is rooted in a Hippocratic tradition and morality. Third, the political, economic, and social aspects associated with medicine should be considered in terms of a philosophically enriched understanding of the final analysis of bioethical issues. The major attributes of Hippocratic m orality can be summarized as follows: the first characteris- tic is that Hippocratic medicine is individualistic, that is, the physician acts always in the best interest of the patient, which implies the moral obligation of beneficent and consequently nonm aleficent. The aim of any medical procedure is the good of the patient independently of other factors, such as the ability to pay or the background of the patient (i. Other characteristics include confidentiality (willing- ness to restrain from divulging information); prohibition to practice euthanasia and abortion; refraining from sexual relationships with patients. In a nutshell, Hippocratic m orality describes the physician as a professional whose etiquette reflects the attributes of a gentleman in his relationship with the patients and his family and his colleagues (Nutton, 1997, p. Interestingly, Ludwig Edelstein remarked that the Hippocratic Oath did not reflect consensus in Greek society concerning medical practice but rather the values and ideology of a small portion of Greek physicians: the document originated in a group representing a small segment of Greek opinion. Medical writings, from the time of Hippocrates down to that of Galen, give evidence of the violation of almost every one of its injunctions. This is true not only in regard to the general rules concerning helpfulness, continence and secrecy. Pellegrino strongly stresses the universal validity of the oath: It was in the early Middle Ages that the ethics of the Hippocratic oath were first universalized. The concept of the physician as a reli- gious man Christian, Moslem, or Jew required him to serve the sick as brothers under the fatherhood of God. The oath was cleansed of its pagan references and found its sources refurbished by the human- ism of the great religions. This is the wellspring for much of medical ethics in nineteenth-century Amer- ica (Pellegrino & Thomasma, 1981, p. Hippocratic medicine became widespread throughout the Judeo-Christian world as a Christian- ized version of the Oath was created. In the context of the Christianity of the first centuries, Hippocratic medicine and its ethical teachings was not dismissed simply on the ground that it was worldly wisdom. According to Owsei Temkin, the Hippo- cratic oath in its pagan form was certainly a major document of medical ethics until at least about the end of the fourth century (Temkin, 1991, p. MacKenney pointed out that in the Middle Ages, Hippocratic ideas concerning the conduct of physicians persisted borrowing [much more] from Hippocrates than from Biblical and clerical authorities... From the non- medical viewpoint of lay historians who are interested in pre-Renaissance classicism, the evidence pre- sented is noteworthy. However, some scholars have pointed out that the Oath s historical value is rather problematic. Vivian Nutton likewise remarks that the Oath was rarely men- tioned in Antiquity as a core reference in medical ethics and that it may not have generally sworn until the sixteenth century at the earliest (Nutton, 1995, p.

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The incubation period of the disease is about ve years: symptoms purchase coumadin 5 mg mastercard, however discount coumadin 1mg visa, can take as long as 20 years to appear order coumadin 1 mg with amex. The infection could affect nerves by direct invasion or during immunological reactions. In rare instances, the diagnosis can be missed, because leprosy neuropathy may present without skin lesions (neuritic form of leprosy). Patients with this form of disease display only signs and symptoms of sensory impairment and muscle weakness, posing difculties for diagnosis, particularly in services where diagnostic facilities such as bacilloscopy, electroneuromyography and nerve biopsy are not available. Delay in treatment is a major problem, because the disease usually progresses and the resulting disability if untreated may be severe, even though mycobacteria may be eliminated. Delay in treat- ment is, however, usually a result of delayed presentation because of the associated stigma. People with long-term leprosy may lose the use of their hands or feet because of repeated injury resulting from lack of sensation. Bacterial meningitis Bacterial meningitis is a very common cause of morbidity, mortality and neurological compli- cations in both children and adults, especially in children. It has an annual incidence of 4 6 102 Neurological disorders: public health challenges cases per 100 000 adults (dened as patients older than 16 years of age), and Streptococcus pneumoniae and Neisseria meningitidis are responsible for 80% of all cases (20). In developing countries, overall case-fatality rates of 33 44% have been reported, rising to over 60% in adult groups (21). Bacterial meningitis can occur in epidemics that can have a serious impact on large populations. The highest burden of meningococcal disease occurs in sub-Saharan Africa, which is known as the meningitis belt, an area that stretches from Senegal in the west to Ethiopia in the east, with an estimated total population of 300 million people. The hyperendemicity in this area is at- tributable to the particular climate (dry season between December and June, with dust winds) and social habits: overcrowded housing at family level and large population displacements for pilgrim- ages and traditional markets at regional level. Because of herd immunity (whereby transmission is blocked when a critical percentage of the population had been immunized, thus extending protection to the unvaccinated), the epidemics occur in a cyclical fashion. Meningitis is characterized by acute onset of fever and headache, together with neck stiffness, altered consciousness and seizures. Antibiotic treatment is effective in most cases but several neurological complications can remain, such as cognitive difculties, mo- tor disabilities, hypoacusia and epilepsy. In a recent review, treatment with corticosteroids was associated with a signicant reduction in neurological sequelae and mortality (22). Progress is more likely to come from investigations into preventive measures, especially the use of available vaccines and the development of new vaccines. Meningitis caused by Haemophilus inuenzae type B has been nearly eliminated in developed countries since routine vaccination with the H. The approval in 2005 of a conjugate meningococcal vaccine against serogroups A, C, Y and W135 is also an important advance that may decrease the incidence of this devastating infection. Local and nationwide surveillance, in- cluding the laboratory investigation of suspected cases, is critical for early detection of epidemics and the formulation of appropriate responses. Tetanus Tetanus is acquired through exposure to the spores of the bacterium Clostridium tetani which are universally present in the soil. The disease is caused by the action of a potent neurotoxin produced during the growth of the bacteria in dead tissues, e. Tetanus is not transmitted from person to person: infection usually occurs when dirt enters a wound or cut. At the end of the 1980s, neonatal tetanus was considered a major public health problem. A worldwide total of 213 000 deaths were estimated to have occurred in 2002, 198 000 of them concerning children younger than ve years of age (23). Unlike poliomyelitis and smallpox, the disease cannot be eradicated because tetanus spores are present in the environment. Once infection occurs, mortality rates are extremely high, especially in areas where appropriate medical care is not available. Neonatal tetanus can be prevented by immunizing pregnant women and improving the hygienic conditions of delivery. Adult tetanus can be prevented by immunizing people at risk, such as work- ers manipulating soil; others at risk of cuts should be also included in the prevention measures. The adult tapeworm (at, ribbon-like, approximately 2 4 m long) lives only in the small intestine of humans, who acquire it (taeniasis) by eating undercooked pork containing the viable larvae or cysticerci. A tapeworm carrier passes microscopic Taenia eggs with the faeces, contaminating the close en- vironment and contacts and causing cysticercosis to pigs and humans. Human beings therefore acquire cysticercosis through faecal oral contamination with T. Thus, vegetar- ians and other people who do not eat pork can acquire cysticercosis. Recent epidemiological evidence suggests that the most common source of infective eggs is a symptom-free tapeworm carrier in the household.

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The solubility of the methylxanthines is low unless they form salts or complexes with other compounds such as ethylenediamine (as in aminophylline) order coumadin 2mg amex. Theophylline is rapidly absorbed after oral buy 1 mg coumadin with amex, rectal order 1 mg coumadin overnight delivery, or parenteral administration, and maximum serum levels occur 2 hours after ingestion on an empty stomach. Most theophylline preparations in current use are sustained release and administered once or twice a day. High-protein, low-carbohydrate diets and diets high in charcoal-grilled foods, as well as smoking tobacco and marijuana, may increase theophylline clearance and therefore decrease serum levels. The clinical effects of theophylline are primarily relaxation of smooth muscle in pulmonary arteries and airways ( 150), increased respiratory drive during hypoxia ( 157), and decreased fatigue of diaphragmatic muscles (152). Theophylline also increases mucociliary clearance and decreases microvascular leakage of plasma into airways ( 153). In recent years, modest antiinflammatory effects of theophylline have been reported. Theophylline inhibits eosinophil infiltration into the airways of asthmatics (154,155). Withdrawal of theophylline in patients treated with both theophylline and inhaled corticosteroids has been reported to result in increased numbers of total + and activated eosinophils in the airways ( 156). Challenge Studies In several studies it is reported that theophylline inhibits bronchial hyperresponsiveness to methacholine ( 159,160 and 161). In other studies, theophylline inhibits the early-phase but not the late phase response to inhaled allergen ( 162,163 and 164). Efficacy Studies have demonstrated that theophylline is similar in efficacy but less well tolerated than cromolyn ( 165,166). A recent comparison study with the leukotriene antagonist zileuton found that it was as effective as theophylline and had fewer unpleasant side effects ( 167). Theophylline is more effective as maintenance therapy than long-acting oral albuterol or inhaled albuterol four times daily ( 168,169). Inhaled beclomethasone dipropionate and inhaled fluticasone have superior efficacy to theophylline for moderate to severe bronchial asthma, and the inhaled corticosteroids have fewer adverse effects ( 170,171). The addition of theophylline to low-dose budesonide was as effective as doubling the dose of budesonide in one study of moderate asthma (172). Low-dose budesonide was superior to theophylline in the treatment of nocturnal asthma, and adding theophylline to budesonide provided no additional benefit ( 173). However, salmeterol has similar efficacy and fewer side effects (174,175,176 and 177). In most comparison studies, more patients withdrew from theophylline treatment groups because of inability to tolerate the drug. In the past, intravenous theophylline has been considered to be a standard therapy for status asthmaticus. However, recent studies in adults and children have reported that theophylline offers little additional benefit to corticosteroids and beta 2 agonists in hospitalized asthmatics ( 178,179 and 180). Safety and Drug Interactions Theophylline is a drug with a narrow therapeutic index. In a 10-year prospective study of theophylline overdoses referred to the Massachusetts Poison Control Center, there were 356 cases in which the theophylline level was greater than 30 g/mL. In addition to potentially life-threatening side effects, theophylline has unpleasant side effects that patients may find intolerable. Side effects such as headache, irritability, nausea, and insomnia may occur even when serum levels are within the therapeutic range. Preparations and Dosing Theophylline is usually prescribed in long-acting tablets or capsules, which come in a number of different dosages, to be administered once or twice a day. It is also available as uncoated tablets, encapsulated sprinkles, in suspension, and as a rectal suppository. For children older than 6 months and adults, the starting dose should be 10 mg/kg up to a maximum initial dose of 300 mg/day. The dosage may be increased every 3 days, if tolerated, up to 16 mg/kg with a maximum dose of 600 mg/day. The peak serum level occurs 8 to 13 hours after the sustained-release preparations and should be 10 to 15 g/mL. Dosage requirements generally maintain stable, but concomitant medications and acute or chronic illness may alter serum levels ( 149). Inhibition of volume-activated chloride currents in endothelial cells by cromones. Effects of cromolyn and nedocromil on ion currents in canine tracheal smooth muscle. Chloride transport and the actions of nedocromil sodium and cromolyn sodium in asthma.

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