The exact trigger is unknown, but it is thought that, whatever the stimulus, chemical mediators produced by cells of the immune system or elsewhere in the body spread and sustain an in?ammatory reaction. Cascade mechanisms with multiple interactions are provoked. CYTOTOXIC substances (which damage or kill cells) such as oxygen-free radicals and PROTEASE damage the alveolar capillary membranes (see ALVEOLUS). Once this happens, protein-rich ?uid leaks into the alveoli and interstitial spaces. SURFACTANT is also lost. This impairs the exchange of oxygen and carbon dioxide in the lungs and gives rise to the clinical and pathological picture of acute respiratory failure.
The typical patient with ARDS has rapidly worsening hypoxaemia (lack of oxygen in the blood), often requiring mechanical ventilation. There are all the signs of respiratory failure (see TACHYPNOEA; TACHYCARDIA; CYANOSIS), although the chest may be clear apart from a few crackles. Radiographs show bilateral, patchy, peripheral shadowing. Blood gases will show a low PaO2 (concentration of oxygen in arterial blood) and usually a high PaCO2 (concentration of carbon dioxide in arterial blood). The lungs are ‘sti?’ – they are less e?ective because of the loss of surfactant and the PULMONARY OEDEMA.
Causes The causes of ARDS may be broadly divided into the following:... Medical Dictionary
Since April 1993, local social-services departments have been responsible for assessing what help people need from community-care services: these can include home helps, meals on wheels, sheltered housing, etc. Recipients of such services are means-tested and make variable contributions towards the costs. Policies on charging vary from one area to another and there are wide geographical variations in the range of services provided free and the charges levied for others.
People with complex needs may be assigned a case manager to coordinate the care package and ensure that appropriate responses are made to changing circumstances. The success of community care hinges on e?ective coordination of the services of an often large number of providers from the health and social-services sectors. Poor communication between sectors and inadequate coordination of services have been among the most common complaints about the community-care reforms.
Health care for people being cared for in the community remains largely free under the NHS arrangements, although there are regular debates about where the boundaries should be drawn between free health services and means-tested social care. A distinction has been made between necessary nursing care (funded by the state) and normal personal care (the responsibility of the patient), but the dividing line often proves hard to de?ne.
As care has shifted increasingly into the community, previous hospital facilities have become redundant. Vast numbers of beds in long-stay geriatric hospitals and in-patient psychiatric wards have been closed. There is now concern that too few beds remain to provide essential emergency and respite services. In some areas, patients ?t for discharge are kept in hospital because of delay in setting up community services for the elderly, or because of the inability of the local authority to fund appropriate care in a nursing home or at home with community-care support for other patients; the resulting BED-BLOCKING has an adverse e?ect on acutely ill patients needing hospital admission.
Community care, if correctly funded and coordinated, is an excellent way of caring for people with long-term needs, but considerable work is still needed in Britain to ensure that all patients have access to high-quality community care when they need it. Problems in providing such are are not con?ned to the UK.... Medical Dictionary
The new Council for Healthcare Regulatory Excellence will help to promote the interests of patients and to improve co-operation between the existing regulatory bodies – providing, in e?ect, a quality-control mechanism for their activities. The government and relevant professions will nominate individuals for this overarching council. The new council will not have the authority to intervene in the determination by the eight regulatory bodies of individual ?tness-to-practise cases unless these concern complaints about maladministration.... Medical Dictionary
The principle of one-to-one, 24-hours-a-day care for seriously ill patients has been widely adopted and developed for the initial treatment of many patients with life-threatening conditions. Thus, severely injured patients – those with serious medical conditions such as coronary thrombosis or who have undergone major surgery, and individuals su?ering from potentially lethal toxic a?ects of poisons – are treated in an INTENSIVE THERAPY UNIT (ITU). Patients whose respiratory or circulatory systems have failed bene?t especially by being intensively treated. Most patients, especially post-operative ones, leave intensive care when their condition has been stabilised, usually after 24 or 48 hours. Some, however, need support for several weeks or even months. Since 1952, intensive medicine has become a valued specialty and a demanding one because of the range of skills needed by the doctors and nurses manning the ITUs.... Medical Dictionary
careful control of symptoms, especially PAIN.
psychosocial and spiritual care.
a personalised management plan centred on the patient’s needs and wishes.
care that takes into account the family’s needs and that is carried into the bereavement period.
provision of coordinated services in the home, hospital, day-care centre and other facilities used by the patient. Palliative care should include: managing
chronic cancer pain with planned use of common ANALGESICS including opioids (see SYRINGE DRIVERS); planning ahead to preserve as far as possible the patient’s autonomy and choice as death approaches and the ability to make decisions may decline; and an understanding and use of arti?cial feeding and hydration. Palliative care seeks to improve the satisfaction of both patient and family, to identify their needs and, if possible, to reduce the overall cost because the patient can often be looked after at home or in a HOSPICE instead of in hospital.
A well-publicised question that may arise in the context of palliative care is physician-assisted suicide. This subject is referred to in the entry on ETHICS. A request by a patient for accelerated death may suggest that he or she is depressed – a treatable condition – or that the palliative care is inadequate and needs reviewing and, if possible, improving.... Medical Dictionary
Intrauterine contraceptive device (IUCD) This, in e?ect, is a form of post-coital contraception. The IUCD is a plastic shape up to 3 cm long around which copper wire is wound, carrying plastic thread from its tail. Colloquially known as a coil, it acts by inhibiting implantation and may also impair migration of sperm. Devices need changing every 3–5 years. Coils have generally replaced the larger, non-copper-bearing ‘inert’ types of IUCD, which caused more complications but did not need changing (so are sometimes still found in situ). They tend to be chosen as a method of contraception (6 per cent) by older, parous women in stable relationships, with a generally low problem rate.
Nevertheless, certain problems do occur with IUCDs, the following being the most common:
They tend to be expelled by the uterus in women who have never conceived, or by a uterus distorted by, say, ?broids.
ECTOPIC PREGNANCY is more likely.
They are associated with pelvic infection and INFERTILITY, following SEXUALLY TRANSMITTED DISEASES (STDS) – or possibly introduced during insertion.
They often produce heavy, painful periods (see MENSTRUATION), and women at high risk of these problems (e.g. women who are HIV positive [see AIDS/HIV], or with WILSON’S DISEASE or cardiac lesions) should generally be excluded – unless the IUCD is inserted under antibiotic cover.... Medical Dictionary
Certain specialties – for example, orthopaedic and reconstructive/cosmetic surgery and mental health – attract more private patients than others, such as paediatrics or medicine for the elderly. The standards of clinical care are generally the same in the two systems, but private patients can see the specialist of their choice at a time convenient to them. Waiting times for consultations and treatment are short and, when in hospital, private patients usually have their own room, telephone, TV, open visiting hours, etc.
A substantial proportion of private medical-care services are those provided for elderly people requiring regular nursing care and some medical supervision. The distinction between residential care and nursing care for the elderly is often blurred, but the government policy of providing means-tested state funding only for people genuinely needing regular nursing care – a system operated by local-authority social-service departments in England and Wales – has necessitated clearer de?nitions of the facilities provided for the elderly by private organisations. The strict criteria for state support (especially in England), the budget-conscious approach of local authorities when negotiating fees with private nursing homes, and the fact that NHS hospital trusts also have to pay for some patients discharged to such homes (to free-up hospital beds for new admissions) have led to intense ?nancial pressures on private facilities for the elderly. This has caused the closure of many homes, which, in turn, is worsening the level of BED-BLOCKING by elderly patients who do not require hospital-intensity nursing but who lack family support in the community and cannot a?ord private care.... Medical Dictionary