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Advantages over morphine are used carefully discount nemasole 100 mg online, and an electrocardiogram should be per the absence of active metabolites nemasole 100 mg online. Constipation is less pronounced when there is clinical evidence of nerve structure com as compared to order 100 mg nemasole fast delivery morphine. Disadvantages include adhe pression or pain due to edema surrounding the metas sive problems and the slow onset of action (when the tases. Dexamethasone has two other ?side ef to its long elimination half-life of 24 hours (up to 130 fects that might be helpful for palliative treatment. Switching to or starting with Excitatory neurotransmitters, such as glutamate, play a methadone might be di? For this reason an algo major role in pain transmission at the spinal cord level. On days ered, especially in situations when opioid analgesia is 2?3, a dose maximal increment of 30% might be neces not e? If pain relief is still not adequate or if pain increases due to cancer progression, Newer classes of drugs to treat neuropathic pain are dose adjustments might be performed. Over the follow provide relief from neuropathic pain, improve appetite, ing days, dose adjustments should be performed as de and reduce nausea and vomiting. Due to its metabolism via cytochrome cannot be recommended in general, due to the lack of P-450, precautions have to be taken to prevent drug in well-designed studies in the area of cancer-related neu teractions. Lung Cancer with Plexopathy 161 Nonpharmacological Approaches cold spoon) give strong evidence of a neuropathic pain syndrome. In cases of neuropathic pain, a combination of dural opioid application and continuous infusion of lo anticonvulsants, antidepressants, and opioids cal anesthetics via a brachial plexus catheter. Cordotomy is a neurodestructive procedure in which the anterolateral spinothalamic tract is destroyed References to produce contralateral analgesia. Neurological manifestations of neoplastic and radiation resis, ataxia, phrenic nerve paralysis, and in long-term induced plexopathies. Being Lung cancer is the most common lung tumor and the able to move a lot better, Mr. The incidence in his dyspnea and exhaustion following relatively short dis Europe is estimated by the World Health Organiza tances of walking. He was sent to Atba cause of death by cancer within the male population, ra for further examination. Furthermore, scintigraphic and X-ray ex Case report?part one aminations reveal scattered bone metastases, such as in Mr. Tarik Al-Khater is a 65-year-old man with an ath the lumbar spine and the right knee. He used to work as a postman in Bar bar, Northern Sudan, and remained active doing? Ten at the age of 63, he received a diagnosis of pulmonary emphysema and dia or tuberculosis). Furthermore, there remained to dust and particles such as asbestos, chromates, and a mixed pain syndrome of the lower back, right hip, and polycyclic aromatics or to radiation from uranium, ra right knee, with a dominating neuropathic component don, or even medical radiation therapy. This material may be used for educational 163 and training purposes with proper citation of the source. Other primary symptoms are What are the disease trajectory hemoptysis, dyspnea or chest pain, and rarer symptoms and treatment options? Other malignancies or coid impaction, retrostenotic pneumonia, hemorrhage, space-consuming processes of the thorax are pleural or pleural e? The regional spreading of the tumor mesotheliomas, thymomas, metastases of extrathoracic follows continuous in? Terefore it was decided that a surgical resection tity and location of the metastases. Common locations (cumulative dose of 46 Gy) following radiation of the of dissemination of lung cancer are thoracic and cer bone metastasis at the spine (36 Gy) and the knee (8 vical lymph nodes, bone, pleura, the brain and its lin Gy). In the course of treatment, blood testing revealed ings, the liver, and the adrenal glands.

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But efforts to order nemasole 100 mg online reduce the Cesarean section rate were only temporarily success ful cheap 100mg nemasole visa. After declining to order cheap nemasole on-line just under 20 per cent in the late 1980s and early 1990s, the incidence of surgical birth began to increase again in the mid 1990s, this time quickly and dramatically. These outspoken and controversial physicians claimed that such intervention is often chosen by birthing women, and that obste tricians should respect their patients preferences for surgical birth. Indeed, proponents of elective Cesarean argue that surgical birth is now almost always safer than vaginal birth for the foetus/newborn, and that the short term risks of surgery (including risk of infection, adverse drug reaction, uterine rupture, and death) for women are offset by the long term risks of vaginal delivery, which include the increased likelihood of incontinence and diminished vaginal ?tone (Walters, 1998; see also Elliott, 2001; Young, 2001). Opponents of elective Cesarean argue that this analogy assumes that childbirth is, like breast cancer, a disease, and is, therefore, misleading. By contrast, they aver, to permit women to choose Cesarean birth for non-medical reasons is analogous to allowing a healthy person to ?choose a kidney transplant or to give antibiotics to a person with a viral infection. In both cases, they argue, the ?treatment is unnecessary, poten tially harmful and costly to the wider community (Wagner, 2000). Feminism and childbirth reconsidered the debate over elective Cesarean brings to the fore many of the issues and concerns raised in the feminist literatures on childbirth regarding choice, technology, and medicalization. In what follows, I discuss these three issues and offer some concluding thoughts regarding the (re)construction of a feminist politics and theory of childbirth. Beckett: Choosing Cesarean 263 for/enjoyment of it ought not to be seen as a kind of false consciousness or, in Bourdian terms, misrecognition. The fact that many birthing women choose and experience positively pharmacological pain relief provides compelling evidence for this argument. This option was made available as a result of feminist agitation, and many women continue to choose it when possible. On the other hand, there is evidence that women make choices regard ing medical technology including pharmaceutical pain relief on the basis of very partial and biased information about their risks and bene? More generally, studies indicating that considerations of both convenience and pro? It is also evident that diagnostic technologies frequently overstate the risks posed to the foetus (Lent, 1999). Even when these factors are relevant, patients choose or consent to this intervention in the vast majority of cases. The question thus arises: what if a woman is pleased with her ?choice to induce labour or deliver surgically but did so because the risks of continuing to labour to herself, or, more likely, her foetus/baby were signi? Further complicating matters, the normative and emotional grounds upon which some women choose obstetrical interventions such as labour induction and Cesarean delivery may be re? For example, one of the main arguments for elective Cesarean section is that vaginal delivery poses long term risks to the mother, including (and, it appears, especially) the loss of ?vaginal tone and therefore of sexual pleasure. Should this experience be treated as evidence of the empowering potential of medical technology? In short, ignoring the grounds upon which women make their choices may not be compatible with feminists commitment to minimizing the in? As Hirschmann argues, social constructionism is not simply concerned with rhetoric, but ?requires us to think about the context in which choices are made (2003: 39). This kind of ?deep construc tionism also goes well beyond the idea that women are simply socialized to accept and internalize ?dominant values. There is ample reason to suspect that both the devaluation of women and medical interests are relevant to those processes. On the other hand, the historical context, political purposes, bodily effects, and material consequences of these discourses cannot be ignored. Consideration of these consequences allows us to begin to assess the validity of the ?high-tech approach to childbirth. Contextualizing medicine and medicalization One of the most powerful aspects of the third wave critique is the recog nition that ?the natural is as much a cultural category as ?the medical, and that attempts to revive traditional birthing practices or legitimate new ones on the grounds that those practices more closely approximate ?nature are misguided. Thus, we cannot choose between the notion that childbirth is natural or that it is disease-like on philosophical or abstract grounds. On the other hand, the practices associated with treating childbirth as if it were medical or natural in nature can and should be evaluated.

According to nemasole 100 mg online these analysts cheap nemasole 100 mg, doctors used their growing political and cultural authority to purchase nemasole 100mg without prescription rede? Daly, 1978; Ehrenreich and English, 1973; Oakley, 1980; Sullivan and Weitz, 1988). While medical propaganda may indeed have shaped popular percep tions of childbirth and helped to associate doctors and hospitals with safety, historical scholarship indicates that women had long expressed a great deal of fear and trepidation about the potential pain (and danger) of childbirth. These activists were outraged by obstetricians reluctance to provide pharmacological pain relief, and saw this reluctance as indicative of physicians tendency to place their own interests ahead of those of their female patients (Leavitt, 1984: 177). Scopolamine was eventually shown to be quite harmful to infant health, and its use subsequently declined. Beginning in the 1960s, increasing numbers of women began to wonder aloud if childbirth had to be ?a time of alienation from the body, from family and friends, from the community, and even from life itself (Wertz and Wertz, 1977: 173). Advo cates of ?natural birth in which a woman was ?awake and aware through out the birth process emerged in this context. As early as 1940, these critics decried the impersonality, isolation, and passivity that now characterized childbirth. In 1944, the English obstetrician Grantly Dick-Read published Birth Without Fear in the United States, which argued that much of the pain associated with childbirth was a product of fear. These ideas spawned what became known as the ?natural childbirth movement (Rothman, 1982). Although hardly couched in feminist rhetoric, these early criticisms replete with the idiom of ?the natural had a signi? The alternative birth movement emerged as an increasingly coherent and united movement in the United States and other industrialized countries in the late 1960s and early 1970s. The alternative birth movement has nevertheless offered a fairly coherent critique of the conven tional approach to childbirth, one that emphasized the importance of treating childbirth as an important life experience and family event rather than a medical emergency; the right of women and families to choose their birth setting and attendants; the inhumane and impersonal nature of many routine hospital procedures; and the counter-productive nature of the ?high-tech, low-touch approach to childbirth. Birth as a natural phenomenon As was discussed previously, second wave feminist birth activists and scholars place a great deal of emphasis on the role of the (male) medical profession in the relocation and transformation of childbirth (see Daly, 1978; Ehrenreich and English, 1973; DeVries, 1996; Leavitt, 1983, 1984; Oakley, 1993; Sullivan and Weitz, 1988). According to these accounts, obstetricians argued ?again and again that normal pregnancy and parturi tion are exceptions and that to consider them to be normal physiologic conditions was a fallacy (Kobrin, 1984); this re-de? As a result, resistance to medical control of childbirth has been framed in the language of ?normality or the idiom of ?natural (Kobrin, 1984; Michie and Cahn, 1996). Still today, birth activists emphasis on the ?normality and ?naturalness of birth is best understood as part of an effort to contest medical control of birth and to challenge the increasingly narrow de? For example, when women give birth in hospital settings, their capacity to act upon their preferences (such as eating or drinking, moving about, and so forth) is limited. In addition, procedures that made labour and delivery more comfortable for physicians and more dif? Birth activists also cite evidence of the safety of home birth to justify their emphasis on the normality and ?naturalness of birth. Indeed, many epidemiological studies indicate that planned home births attended by trained midwives are as safe or safer than physician-attended hospital births for ?low risk women (for summaries of these literatures, see Goer, 1995; Rooks, 1997; Wagner, 2000). Birth activists conclude that since midwives, operating from a conception of birth as ?natural, are able to match or exceed doctors safety record at lower cost, the pathologization of birth is not just unnecessary, but epistemologically and empirically incorrect. The iatragenic and dehumanizing nature of medical intervention Second wave birth scholars and activists emphasize that the vast majority of births involve high and increasing levels of technological interven tion. These rates far exceed World Health Organization standards for maternity care, and are, therefore, the subject of much controversy (Wagner, 1997, 2000). As was discussed previously, high levels of intervention are considered problematic because obstetric intervention often results from misleading indicators of risk or narrowed de? Some birth activists also register concern about the loss of intimacy that resulted from the modernization and bureaucratization of birth: hospital births, replete with ?the cool penetration of needles, the distant interpret ation of lines on a graph deprive women of ?the warm exchange of breath and sweat, of touch and gaze, of body oils and emotions that characterize births in which there is an intimate connection between the mother and her caretaker (Davis-Floyd and Davis, 1997: 315). As this quote suggests, the loss of familiar, female supporters during birth and the intimacy of home is a pervasive theme in the literature of the alternative birth movement (see also Leavitt, 1984). As political activist and scholar Angela Davis put it at a hearing on the issue in California in 1981: As growing numbers of medically indigent women are forced to go without prenatal care and proper nutrition, thus producing very low birth weight babies, every effort is made to keep those infants alive. Such a system ignores the under and uninsured, and creates incentives to over-treat those with private insurance. This argument has found support in empirical studies: women of higher socio-economic status, who give birth in private hospitals and have private insurance, are more likely to give birth surgically, despite having ?lower risk pregnancies and deliveries (Gould et al. Given that physician-attended birth has become the norm, this has largely meant the right to choose a midwife-attended, out-of-hospital birth.

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Post-prandial chest discomfort nemasole 100 mg amex, especially if associated with radiation to buy 100mg nemasole with visa the back or abdomen and accompanied by nausea purchase nemasole 100mg without prescription, is suggestive of gallbladder disease. In case of suspected esophageal disease, gastroenterolo gy referral is indicated. Spinal diseases Chest pain is frequently caused by osteochondro sis (including hernias of intervertebral discs, espe cially those of cervical spine) and osteoarthrosis of cervical and thoracic spine. Pain in spinal disease Clinical Practice Guidelines for General Practitioners 25 Chest Pain is described as dull and gnawing, may be located in any area of the chest, including sternal area, and worsens during strain, movements and deep breathing. In case of suspected spinal disease, patient should be referred to neurologist and other specialists, as necessary. Psychogenic pain Psychogenic pain is typically located in the cardiac area and usually does not radiate. Although resembling angina, it lasts significantly longer several hours or even days. Chest pain caused by anxiety or emotional stress most commonly occurs in healthy young men or women, but it can occur at any age. In case of suspected psychogenic pain, patient should be referred to neurologist or psychiatrist, as necessary. Chest pain in the elderly In elderly people, chest pain is primarily caused by cardiovascular disease. In elderly patients complaining of chest pain, angina pectoris and myocardial infarction should be considered first. Pain may be also caused by 26 Clinical Practice Guidelines for General Practitioners Chest Pain herpes zoster, fractured ribs, pleurisy, malignant neoplasm, pulmonary thromboembolism, reflux esophagitis, etc. Chest pain in disorders of m uscles, bones and joints Patient history and physical examination usually provide sufficient information for identifying dis orders of muscles, bones, and joints. M uscular chest pain is the most frequent diagnosis in active young men and women (25-65 years old). The pain is the result of overuse of chest wall mus cles and a resulting strain within a muscle body or at its insertion site. The characteristic physical examination finding is tenderness to palpation of the chest wall muscles. In many cases, palpation of the affected muscle reproduces the chest pain expe rienced by the patient. When this occurs, the diag 28 Clinical Practice Guidelines for General Practitioners Chest Pain nosis is clear and no additional testing is necessary. Pain may be either sharp and sudden or pro longed and gnawing; it may be worsened by deep breathing, coughing, or sneezing. In very severe pain, injections of local anesthetics and corticosteroids into the affected area are indicated. Injections into the chest wall should be done with extreme caution to avoid injuring parietal pleura. Special elastic bandage proved to be effective (it relieves pain significantly without hampering respiration). Costochondral inflam m ation Costochondral inflammation is characterized by jabbing, unilateral, mild to moderate pain radiat ing to the back and abdomen and worsened by deep breathing and physical exertion; pain is influenced by change of posture. Costochondral inflammation occurs as a result of acute viral respiratory infection or physical overexertion and lasts up to several months. Costochondral inflammation is most often diagnosed in women (25-44 years old) the pain is thought to be due to inflammation of the 3rd or 4th left costochondral junction. Suggestive Clinical Practice Guidelines for General Practitioners 29 Chest Pain history includes pain with use of chest wall muscles. In addition, the pain may occur at rest or with deep inspiration, and there is usually no history of recent trauma or muscular exertion. The characteristic physical finding is tenderness to palpation over a costochondral junction. If the patient has tried them, anti-inflammatory agents have often provided relief. Back pain Back pain is usually caused by spinal disease; osteoarthrosis affecting costovertebral articula tions is among the most common causes.

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The Impact of Contraception on Maternal Mortality in Indonesia Shofwal Widad purchase nemasole 100mg mastercard, Department of Obstetrics and Gynaecology buy nemasole 100mg low cost, Faculty of Medicine buy generic nemasole on-line, Gad jah Mada University, Yogyakarta, Indonesia 1 Maternal mortality in Indonesia Indonesia is an archipelagic country in Southeast Asia, comprising approximately 17,508 islands, with a land area of 1,910,931 square kilometers. The distance from Sabang, the west endpoint, to Merauke, the east endpoint, is approximately 5,233 km. It has 33 provinces, 399 regencies (districts) and 98 municipalities: It has a population growth rate of 1. Indonesia is one of 11 countries that account for 65 percent of all maternal deaths worldwide. Hypertensive disorders have different etiopathogenesis and are more similar to the leading causes of ma ternal death in developed countries. Both causes, which contribute to 50 percent of total maternal death, usually occur around the time of childbirth and the key to handle this issue is to attain timely comprehensive emergency obstetric care to avoid maternal death. The goal of this programme was to place a skilled birth attendant in every village to provide antena tal and perinatal care, family planning, other reproductive health services, and nu trition counseling (Figure 3). The attendants were also there to facilitate basic pri mary health care services, including immunization and nutrition interventions. At its inception in 1989, the village-based midwife programme faced the staggering target of training and placing 54,000 midwives throughout a vast archipelago with in 7 years. By 1997, over 96 percent of the population of Indonesia had access to 54,000 village-based midwives, many of whom were equipped with small birthing units. In rural areas, births which have been attended by skilled midwives in creased from 22 percent to 55 percent between 1990 and 2003, and socio economic inequalities were reduced for professional attendance at births. Not all primary health centers can provide basic obstetric care, and about 34 percent of district public hospitals do not have an obstetrician, indicating limited provision of 24 hours continuum of care necessary for dealing with emer gency situations and comprehensive obstetric care. High parity mother and her baby: beneficiaries of skilled attendance in Bajawa District Hospital, East Nusa Tenggara, Indonesia Figure 4. The unmet need for contra ception varies greatly among provinces, regions, and socio-economic status. The more educated and wealthy group has better access to information and services of family planning and reproductive health. In addition, higher unmet need was found in the lowest socio economic level (13 percent) compared to the highest socio-economic level (8 per cent). An agenda to reduce maternal mortality beyond 2015 is needed in cluding continuous efforts for regarding family planning as something important and thus, improve the unequal coverage of family planning among provinces with in the country. Maternal-Child Health Interdiscplinary Aspects Within the Perspective of Global Health 471 4 How contraceptive use affects maternal mortality In 1987, the Safe Motherhood Initiative, a global campaign and movement to reduce maternal mortality was launched. It identified family planning as one of four strategies to reduce maternal mortality in developing countries, where 99 per cent of all maternal deaths took place. Family planning programs that support the use of mod ern contraceptives have direct and indirect effects to reduce maternal mortality. Contra ception coverage is 61 percent in the world, while unmet need for contraception ranges from 6 percent in European countries to 23 percent in the countries of sub Saharan Africa. The unmet need for contraception leads to unwanted pregnancies, which in turn lead to termination of pregnancies. In turn, abor tion complications contributed to 13 percent of total maternal deaths worldwide. These data show that about 20-25 percent of maternal deaths could be eliminated if unplanned and unwanted pregnancies were prevented. So, fewer births lead to lower risk of maternal death and finally results in less total number of deaths. As abortion is illegal in Indonesia, many pregnant women seek unsafe abortion ser vices. In places where induced abortion is prohibited or illegal, actual events can only be estimated indirectly. Statistics about abortion often do not reflect actual number of events, as many events are hidden. Official data from the Ministry of Health (Figure 2) showed that 5 percent of maternal deaths were caused by abor tion complications, but actual events were estimated higher, about 6-16 per cent. Ma ternal mortality risk is higher than average in young women (less than 18 years; ?too young) because pelvic development is incomplete.

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