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By O. Sulfock. Southampton College.

She has experienced similar painful episodes in the past buy cheap accutane 30 mg online, usually in the evening following heavy meals buy accutane on line amex, but the episodes always resolved spon- taneously within an hour or two discount 5mg accutane. She is married, has three children, and does not drink alco- hol or smoke cigarettes. On examination, she is afebrile, tachycardic with a heart rate of 104 bpm, blood pressure 115/74 mm Hg, and shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her leukocyte count is 16,500/mm3 with 82% polymorphonuclear cells and 16% lymphocytes. A plain film of the abdomen shows a nonspecific gas pattern and no pneumoperitoneum. She also has hyperbiliru- binemia and an elevated alkaline phosphatase level, suggesting obstruction of the common bile duct caused by a gallstone, which is the likely cause of her pancreatitis. Considerations This 42-year-old woman complained of episodes of mild right upper quadrant abdominal pain with heavy meals in the past. However, this episode is dif- ferent in severity and location of pain (now radiating straight to her back and accompanied by nausea and vomiting). The elevated amylase level confirms the clinical impression of acute pancreatitis. The next most common cause is biliary tract disease, usually due to passage of a gallstone into the common bile duct. Hypertriglyceridemia is another common cause and occurs when serum triglyceride levels are more than 1000 mg/dL, as is seen in patients with familial dyslipidemias or diabetes (etiologies are given in Table 14–2). When patients appear to have “idiopathic” pancreatitis, that is, no gallstones are seen on ultrasonography and no other pre- disposing factor can be found, biliary tract disease is still the most likely cause— either biliary sludge (microlithiasis) or sphincter of Oddi dysfunction. The pain often is relieved by sitting up and bending forward, and is exacerbated by food. Patients commonly experience nausea and vomiting that is precipitated by oral intake. They may have low-grade fever (if temperature is >101°F, one should suspect infection) and often are volume depleted because of the vomiting, inability to tolerate oral intake, and because the inflammatory process may cause third spac- ing with sequestration of large volumes of fluid in the peritoneal cavity. The most common test used to diagnose pancreatitis is an elevated serum amylase level. It is released from the inflamed pancreas within hours of the attack and remains elevated for 3 to 4 days. Amylase undergoes renal clearance, and after serum levels decline, its level remains elevated in the urine. Amylase is not specific to the pancreas, however, and can be elevated as a consequence of many other abdominal processes, such as gastrointestinal ischemia with infarction or perforation; even just the vomiting associated with pancreatitis can cause elevated amylase of salivary origin. Elevated serum lipase level, also seen in acute pancreatitis, is more specific than is amylase to pancreatic origin and remains elevated longer than does amylase. Treatment of pancreatitis is mainly supportive and includes “pancreatic rest,” that is, withholding food or liquids by mouth until symptoms subside and adequate narcotic analgesia, usually with meperidine. In patients with severe pancreatitis who sequester large volumes of fluid in their abdomen as pancreatic ascites, sometimes prodigious amounts of parenteral fluid replace- ment are necessary to maintain intravascular volume. Patients with adynamic ileus and abdominal distention or protracted vomiting may benefit from naso- gastric suction. When pain has largely subsided and the patient has bowel sounds, oral clear liquids can be started and the diet advanced as tolerated. Several criteria have been developed in an attempt to identify the 15% to 25% of patients who will have a more complicated course. When three or more of the following criteria are present, a severe course complicated by pan- creatic necrosis can be predicted by Ranson criteria (Table 14–1). The most common cause of early death in patients with pancreatitis is hypovolemic shock, which is multifactorial: third spacing and sequestration of large fluid volumes in the abdomen, as well as increased capillary permeability. Pancreatic complications include a phlegmon, which is a solid mass of inflamed pancreas, often with patchy areas of necrosis. Either necrosis or a phlegmon can become secondarily infected, resulting in pancreatic abscess. Abscesses typically develop 2 to 3 weeks after the onset of illness and should be suspected if there is fever or leukocytosis. Pancreatic necrosis and abscess are the leading causes of death in patients after the first week of illness. A pancreatic pseudo- cyst is a cystic collection of inflammatory fluid and pancreatic secretions, which unlike true cysts do not have an epithelial lining. Most pancreatic pseudocysts resolve spontaneously within 6 weeks, especially if they are smaller than 6 cm. However, if they are causing pain, are large or expanding, or become infected, they usually require drainage. Any of these local complications of pancreatitis should be suspected if persistent pain, fever, abdominal mass, or persistent hyperamylasemia occurs. Gallstones Gallstones usually form as a consequence of precipitation of cholesterol microcrystals in bile. When discovered incidentally, they can be followed without intervention, as only 10% of patients will develop any symptoms related to their stones within 10 years. When patients do develop symptoms because of a stone in the cystic duct or Hartmann pouch, the typical attack of biliary colic usually has a sudden onset, often pre- cipitated by a large or fatty meal, with severe steady pain in the right upper quadrant or epigastrium, lasting between 1 and 4 hours. They may have mild elevations of the alkaline phosphatase level and slight hyperbilirubinemia, but elevations of the bilirubin level over 3 g/dL suggest a common duct stone. The first diagnostic test in a patient with suspected gallstones usually is an ultra- sonogram. The test is noninvasive and very sensitive for detecting stones in the gallbladder as well as intrahepatic or extrahepatic biliary duct dilation. This is apparent ultra- sonographically as gallbladder wall thickening and pericholecystic fluid, and is characterized clinically as a persistent right upper quadrant abdominal pain, with fever and leukocytosis. Cultures of bile in the gallbladder often yield enteric flora such as Escherichia coli and Klebsiella. The positive test shows visualization of the liver by the isotope, but nonvisualization of the gallbladder may indicate an obstructed cystic duct. Treatment of acute cholecystitis usually involves making the patient npo (nil per os), intravenous fluids and antibiotics, and early cholecystectomy within 48 to 72 hours. Another complication of gallstones is cholangitis, which occurs when there is intermittent obstruction of the common bile duct, allowing reflux of bacteria up the biliary tree, followed by development of purulent infection behind the obstruction. After 3 months she is noted to have severe right upper quadrant pain, fever to 102°F, and nausea. This patient with fever, right upper quadrant pain, and a history of gallstones likely has acute cholecystitis.

Later on cheap accutane online mastercard, as bowel infarction occurs order accutane 30mg on-line, the abdomen becomes grossly distended buy accutane pills in toronto, bowel signs disappear, and features of peritonitis appear. It is vital that the diagnosis is made early, as outcome is much better if interventions are taken early; unfortunately the early features are easily missed. A high index of suspicion should be maintained in any patient with risk factors for bowel ischaemia presenting with rapid onset central abdominal pain. Dobutamine is the best choice because it is thought to have the least vasoconstrictor effect on the splanchnic circulation. Specific therapeutic options are; o Papaverine infusion given intra-arterially following cannulation of the mesenteric artery. This relieves secondary vasospasm o Thrombolysis o Angioplasty and stenting o Embolism is usually treated with surgical embolectomy o If bowel infarction has developed, laparotomy and surgical resection is required Long term anticoagulation with warfarin is usually required. Abdominal problems 225 Handbook of Critical Care Medicine Intestinal obstruction This is often due to mechanical obstruction. Common causes are: o Small intestinal obstruction o adhesions from previous surgeries o hernias o intussusception o malignancy o Crohn’s disease o Colonic obstruction o Colonic carcinoma o Sigmoid volvulus o Diverticular disease Clinical features are of colicky abdominal pain, vomiting and absolute constipation (no passage of stools or flatus). Vomiting is more profuse in small bowel obstruction, and may even be absent in large bowel obstruction. Examine the hernial orifices for possible obstruction, and do a rectal examination. Investigations: plain abdominal radiograph may show distended bowel with multiple fluid levels in small bowel obstruction. Air-insufflation during barium enema (to obtain a double contrast barium enema) is risky and must be performed only with care. Prophylactic antibiotics are usually given; cephalosporins with metronidazole provide reasonable cover. Sigmoid volvulus can sometimes be treated by passage of a flexible sigmoidoscope to un-kink the bowel. If the patient is deteriorating and developing signs of severe sepsis with increasing pain, exploratory laparotomy is indicated. In the case of strangulation or intussusception, the gangrenous Abdominal problems 226 Handbook of Critical Care Medicine bowel is resected and anastomosis peformed. Most large bowel obstruction is due to colon cancer, and resection of the affected bowel is necessary; if possible primary anastomosis is performed. In severely ill patients, a defunctioning colostomy is performed, with secondary anastomosis later, once the patient has recovered. If bowel sounds are normal, and there are no signs of obstruction, this may not be of any serious consequence. Opiate analgesics cause constipation, and calcium channel antagonists such as verapamil are also a cause. Most of the time, simple laxatives such as lactulose, liquid paraffin, or enemas are adequate treatment. Paralytic ileus is common after abdominal surgery, and usually resolves spontaneously. If paralytic ileus persists for longer than 5 days, a plain x-ray abdomen should be performed to exclude mechanical obstruction. Acute colonic pseudo-obstruction or Ogilvie syndrome mimics acute large bowel obstruction, except that there is no mechanical obstruction. Symptoms and signs are similar to mechanical obstruction, and massive dilatation of the large bowel can occur, with perforation. Severe sepsis, electrolye imbalance, abdominal surgery, and steroid use are causes. Surgical decompression maybe required if the colonic diameter exceeds 10cm on plain abdominal radiograph. Toxin-induced gastroenteritis is usually self limiting and rehydration is adequate. If the patient can tolerate oral fluids, oral rehydration solution composed of water, electrolytes and glucose is more effective, as the sodium-glucose co- transport overrides the usual sodium pump. Antibiotic associated colitis or pseudomembranous colitis is a dangerous complication occurring in patients who have been on treatment with broad- spectrum antibiotics. It is a nosocomial infection caused by Clostridium difficile, which colonises the gut when the normal bacterial flora has been altered by antibiotics. Penicillins, cephalosporins and clindamycin are the antibiotics most likely to cause antibiotic associated colitis. Clinical features are watery diarrhoea with lower abdominal pain, fever and leukocytosis starting a few days after antibiotic therapy. The usual time of onset is between 5 and 10 days of starting antibiotics, but may develop earlier or even after cessation of antibiotic therapy. Sigmoidoscopy reveals pseudomembranes, which appear as raised yellow plaques ranging up to 1 cm in diameter scattered over the colorectal mucosa. Severe ulcerative colitis Patients with severe ulcerative colitis can have a fulminant course. Patients should also be given broad spectrum antibiotics with metronidazole, especially if high fever and leukocytosis are present. Prophylactic acid blockade is recommended, and proton pump inhibitors are Abdominal problems 228 Handbook of Critical Care Medicine the most effective. The common causes are: peptic ulcer disease, bleeding oesophageal varices, Mallory-Weiss tears, tumours and arteriovenous malformations. A Sengstaken-Blakemore tube can be used as a temporary measure for up to 24 hours. Antibiotics therapy with norfloxacin or ciprofloxacin is of benefit in reducing infections in cirrhotic patients with upper gastrointestinal bleeding. Urgent upper gastrointestinal endoscopy must be performed if significant bleeding is present. Bleeding from a peptic ulcer can be treated with injection sclerotherapy or thermal coagulation. Endoscopic band ligation is the preferred treatment for oesophageal variceal bleeding. It can be subdivided into: x Hyperacute, in which encephalopathy occurs within seven days of jaundice. Gastrointestinal bleeding, spontaneous bacterial peritonitis, other sepsis, dehydration, electrolyte abnormalities, sedative drugs, portal vein thrombosis, or development of liver carcinoma can cause deterioration, and should be actively looked for. Patients may appear well initially, but can rapidly progress to develop multi-organ failure. Jaundice usually precedes encephalopathy, although occasionally encephalopathy can occur before jaundice, especially in paracetamol poisoning.

The main presenting features are acute upper abdominal pain and tenderness discount 40 mg accutane with visa, with nausea and vomiting order generic accutane pills. These are non-specific buy accutane 40 mg low cost, and the differential diagnosis includes peptic ulcer disease, cholangitis/cholecystitis, inferior myocardial infarction, and mesenteric infarction. Always do a serum amylase or serum lipase in any patient with upper abdominal pain. Sometimes, pain is not prominent, especially if the patient is on analgesics or sedatives. Serum lipase is more sensitive and specific than serum amylase and remains elevated longer. Plain abdominal radiograph will show regional ileus and will also help to exclude intestinal perforation. It should be performed if there is doubt as to the diagnosis, or if there is no improvement within 3 days. Neutrophil leukocytosis maybe present, especially if there is superadded infection. A rise in C-reactive protein over 150mg/dL indicates severe pancreatitis with necrosis. However, within 48 hours, the full clinical picture develops, and clinical assessment is an accurate measure of severity. Age over 60 years, obesity and medical co-morbidity are risk factors for severe pancreatitis. Confusion, hypotension, tachycardia, hypoxaemia and low urine output are signs of impending multi-organ failure. A tense abdomen and the appearance of periumbilical (Cullen’s sign) and flank (Grey Turner’s sign) ecchymoses may indicate the degree of the inflammatory process. Two prognostic scoring systems are used in acute pancreatitis – the Glasgow Scoring System, and the Ranson Scoring System. Hypertriglyceridaemia is a known cause, especially if the serum triglycerides are over 1000mg/dL (11 mmol/L). Hypercalcaemia is also a possible cause, although the incidence of pancreatitis in patients with hyperparathyroidism is low. Acute biliary pancreatitis is due to impaction of a gallstone in the sphincter of Oddi. In severe pancreatitis due to biliary obstruction, endoscopic sphincterotomy with removal of the stone must be performed. The procedure may increase the risk of infection, and broad spectrum antibiotic cover must be given. A lot of vasoactive substances, activated enzymes and inflammatory mediators are generated locally, and this sets up a systemic inflammatory cascade which results in multi-organ dysfunction, which in turn makes the local necrosis worse. Supportive therapy: careful supportive therapy is of paramount importance and will prevent the development of multi-organ dysfunction. Adequacy of resuscitation must be judged by haemodynamic responses and urine output. Pleural effusions may occur (especially on the left), and may need drainage if they compromise respiration. If the patient is haemodynamically unstable, continuous renal replacement therapy will be the preferred modality. Severe abdominal distension due to paralytic ileus resulting in significant intra-abdominal hypertension may take place. Decompression of the colon with a rectal tube or surgically may be required, if abdominal compartment syndrome is developing. Give Stress ulcer prophylaxis with intravenous pantoprazole or omeprazole, usually 40mg twice daily or as a continuous infusion of 8mg per hour. Thoracic epidural block is effective and safe, and will help reduce the dose of systemic opioids, although it is not widely used. Antibiotic prophylaxis: although at the beginning, pancreatitis is a non- infective condition, prevention of secondary bacterial infection in the necrotic areas is essential. The risk of giving prophylactic antibiotics is that it may speed up the selection of certain strains of Staphylococci and Enterococci, and may result in fungal overgrown and multi- resistant gram negative bacteria. Aspiration and culture of the necrotic areas should be performed, and if infection is confirmed, appropriate antibiotics must be given. Blood glucose control: hyperglycaemia must be controlled, usually using an insulin infusion. Hypocalcaemia often occurs, and must be corrected with infusions of calcium gluconate. Surgical drainage: indications for surgery are limited: x Infected pancreatic necrosis. Pancreatitis 250 Handbook of Critical Care Medicine x Severe retroperitoneal haemorrhage: this occurs due to erosion of a blood vessel by proteases. Surgery for removal of large sterile necrosis does not improve survival and is not recommended. However, if multi-organ dysfunction is persisting, presumably because of the toxins being released from the necrotic material, surgical drainage maybe necessary, although this is controversial. Nutrition: adequate nutrition is important in pancreatitis; protein and energy requirements are high because of the hypercatabolic state. Patients may be unable to take orally because of gastric atony and paralytic ileus. Total parenteral nutrition was advocated in the past – the aim being to rest the pancreas. However, jejunal feeding through a jejunal tube is safe and adequate in patients without paralytic ileus, intestinal obstruction or rupture. Enteric feeding is usually given as a 24 hour infusion, starting with around 500ml/day, and increasing according to requirements. Oral feeding can be started once the patient’s condition improves and ileus has resolved. Various other treatments have been evaluated, such as octreotide, somatostatin, glucagon and plasma exchange, but none are of proven benefit. Pancreatic pseudocyst formation This is a collection of pancreatic juice enclosed by a wall of granulation tissue – it is formed from an area of tissue necrosis with rupture of a pancreatic duct into the area. In the absence of insulin, peripheral tissues [muscle, fat, and liver] do not take up glucose. Hyperglycaemia itself reduces any residual insulin secretion and further impairs peripheral glucose uptake. Beta-oxidation of these free fatty ĂĐŝĚƐ ƉƌŽĚƵĐĞƐ ŬĞƚŽŶĞ ďŽĚŝĞƐ͘ <ĞƚŽŶĞ ďŽĚŝĞƐ ΀ĂĐĞƚŽŶĞ͕ ĂĐĞƚŽĂĐĞƚĂƚĞ ĂŶĚ ɴ- hydroxybutrate] deplete extracellular and cellular acid buffers producing acidosis. Excess fatty acids and lactic acidosis, as a consequence of poor tissue perfusion are two other important contributors.

The use of the first person pronoun is evidently intended to involve the reader as an active participant and as a potential donor capable of empathy towards those in need of a blood transfusion: (1) Why should I give blood? In order to provide fresh blood products for treatments of patients with chronic diseases or in need of surgery because of illness or accident generic 30mg accutane, we entirely count on the generosity of our blood donors to donate on a continuous basis accutane 40 mg with visa. In the case of Ireland generic accutane 10mg visa, altruism is the overarching principle, though the mention of “our hospitals” (inclusive we) and the various factors giving rise to the need for transfusions could be interpreted as enlightened self-interest, with altruism being tempered by self-preser- vation: 1 < http://www. The Gift Relationship: Cultural Variation in Blood Donor Discourse 143 (7) Irish Blood Transfusion Service Giving blood makes it possible for many people to lead normal healthy lives. Every year thousands of patients require blood transfusions in our hospitals, because they are undergoing surgery, recovering from cancer or have been in a serious accident. The donor will pro- vide a gift that is a lifesaver, saving up to three lives with one dona- tion and making a difference in the community, while connecting with fellow ‘Kiwis’: (10) Why should I donate blood 144 William Bromwich It isn’t every day you can do something to save someone’s life - but that’s ex- actly what you do every time you donate blood. Your blood donation could help save the life of an accident victim, a patient with severe anaemia, a person undergoing major surgery or even a newborn baby. Al- truism is key to blood donation efforts in Sri Lanka, a particular kind The Gift Relationship: Cultural Variation in Blood Donor Discourse 145 of altruism associated in the official discourse with Buddhist values, particularly generosity. Donation is construed primarily as a collective act timed to coincide with and celebrate Full Moon Day, an annual re- ligious holiday, rather than conceptualised as an individual medical procedure as in Western countries. Sri Lanka has eliminated the prac- tice of collecting from what Titmuss called ‘paid donors’: all blood donations now come from voluntary donors: (13) Sri Lankans attach special importance to the act of blood donation. The day also coincides with Poson Poya (Full Moon Day), an annual religious holiday that marks the arrival of Buddhism in Sri Lanka and is a time for generosity and celebration. One possible explanation for the al- most complete lack of argumentative discourse and the prevalence of informational content is that Sweden has managed to recruit five per cent of the adult population as donors, that compares extremely well with other countries (the figure for Iceland is 2. Donated blood is a lifeline for many people needing long-term treatments, not just in emergencies […] Ever since a national blood service was first created in 1946, we have relied on the generosity of blood donors […]. A ‘special reason’ may be an oblique reference to altruism, but potential donors are not required to donate for altruistic reasons, as other reasons will do just as well. With limited space given to altruistic motives, the psy- chological benefits for the donor are a recurrent theme: (17) I’m a Red Cross blood donor that won’t give up. Most healthy adults are eligible to give blood, however, there are some rea- sons a person may be deferred from donating temporarily, indefinitely, or per- manently. Your blood donations help treat cancer patients, traumatic accident and burn victims, newborn babies and mothers delivering babies, patients undergoing surgery, and many more. This lends further weight to Bhatia’s argument The Gift Relationship: Cultural Variation in Blood Donor Discourse 151 that to achieve an adequate characterisation of a particular genre, the institutional setting should be taken into account. A decision to donate your blood can save a life, or even several if your blood is separated into its components – red cells, platelets and plasma – which can be used individually for patients with specific conditions. Enlightened self-interest In a number of cases there is an appeal to potential donors to reflect on the fact that one day they themselves may need blood donated by others. En- lightened self-interest features prominently in the South African ap- peal: 152 William Bromwich (31) You could be next It’s not a nice thing to consider, but the fact is that you, a close friend, or a family member could well be the next car accident victim or surgery candidate requiring a transfusion. Unlike blood donated to the Red Cross or the Armed Services, it is not allocated to a national blood bank: (32) Giving Blood Saves Lives Your donation will help ensure an adequate supply for both children and adults who are patients within Lee Memorial Health System. Here the line between donors and recipients is blurred: they are no longer conceptualised as separate categories but as a fuzzy set (Lakoff 1987: 22), since donors may themselves need donations in the future. This brings to mind Malinowski’s (1922: 167) observation about gifts and counter-gifts in the Western Pacific as “one of the main instruments of social organisation […] and the bonds of kinship”. Self-interest It was initially expected that the institutional discourse would focus entirely on an appeal to altruism but this expectation was not con- firmed by the data. The following list of reasons to give blood begins with the offer of free juice and cookies, and conti- nues with other supposed benefits such as the chance to lose weight and to be excused from heavy lifting, before reaching the point where the donor is placed “on an equal footing with the rich and famous”. Paradoxically, an act that seems to be emblematic of altruism is moti- vated by a long list of self-centred considerations: (35) Top 10 Reasons to Give Blood The American Red Cross is constantly encouraging people to donate blood. It’s easy and convenient – it only takes about an hour and you can make the donation at a donor center, or at one of the many Red Cross mobile blood drives. The same line of reasoning appears on the Knoji Blood Donation web- site: (36) Donating Blood Is Healthy From a health standpoint, I can’t think of a better way for people with high blood pressure, migraines, or high cholesterol to let go of some waste. I do it to help with my blood pressure and migraines, as unloading two pints of blood [sic] is the best way for me to relieve pressure in my brain and my body. According to studies published in the American Journal of Epidemiology, blood donors are 88% less likely to The Gift Relationship: Cultural Variation in Blood Donor Discourse 155 suffer a heart attack. Urging people to donate blood more often, Harsh Vardhan said: “Regular blood donors, according to medical researchers, are 80 per cent less prone to diseases like heart attack, cancer, etc. Strands of argumentation in the discourse In each of the institutional appeals an attempt was made to identify the predominant strand of argumentation and the results are set out in the following matrix diagram. Although the discourse of altruism (upper left-hand quadrant) is predominant, the discourse of self-interest (up- per right-hand quadrant) also plays a significant role, and enlightened self-interest (lower left-hand quadrant) is also well represented, along with a strand focusing on organisational, scientific and technical is- sues (lower right-hand quadrant). Whereas in the institutional discourse there was a focus on altruism as the main motivation for blood donors, with some atten- tion to enlightened self-interest and organisational, scientific and tech- nical information, in the media reports the focus was primarily on self- interest, mainly considering the health benefits for the donor rather than the recipient. Concluding remarks This study investigated aspects of argumentation in the institutional blood donor discourse of a number of English-speaking countries and states, examining the strands of discourse based on altruism, en- lightened self-interest and self-interest. Institutional and cultural varia- tions were identified, not simply reflecting different national contexts, as in some instances cultural variation was identified also within the same national context. A stark contrast was evident between on the The Gift Relationship: Cultural Variation in Blood Donor Discourse 157 one hand the discourse of the institutional actors, in which altruism tends to prevail, along with elements of enlightened self-interest, and on the other hand the media reports, where self-interest clearly predo- minates. Healthcare professionals seeking to identify a judicious mix between the various motives to persuade blood donors to come forward to become regular donors might wish to compare their discursive practices with those characteristic of media reports as some mutual learning appears to be possible. Regardless of the specific approaches in the various national contexts, it is evident that public health information professionals need to continue to pay close attention to blood donor issues, also exploring the possibilities 3 afforded by social media. To conclude, the ongoing need for effective public health information is evident in this quotation from the Yelp review by a San Diego blood donor who was ‘weirded out’ not by the needles or the blood, but by the ignorance of potential donors: (40) I gave blood on one of their busses today. Introduction In the last two decades, Applied Linguistics and Translation Studies can be said to have experienced a similar shift: both disciplines have increasingly extended their focus of attention on social questions. It is true that the purpose of Applied Linguistics has always been “to solve or at least ameliorate social problems involving language” (Davies 1999: 1): but it is especially with the relatively new branch of Critical Applied Linguistics that issues such as identity, sexuality and power have become central questions to be addressed (Pennycook 2004: 785). Similarly, also Translation Studies have been more and more concerned with social factors involved in translation, with the translator’s social responsibility and issues of translation ethics (see for instance Pym 2006, Baker/Maier 2011). The ‘ethics of difference’ (Venuti 1998) has become a fundamental concept which has opened up many new lines of enquiry and has also influenced the authors of the present chapter. Being particularly interested in matters concerning human rights and vulnerable subjects, we have recently started to investigate communication to disabled people in three languages, i. While in the past, society only recognized the binary distinction between two sexes, it is now gradually accepting the variety that exists in real life. Moreover, this is one of the cases where language does not only express or reflect one’s identity as a particular kind of social subject, but also contributes to constitute it (Pennycook 2004: 393). Against this background, translators, language experts, and other professional communicators may play a fundamental role in identifying and helping to spread the best linguistic and communicative practices. In the field of medical translation and interpreting, the ethical question has been highlighted, among other authors, by Montalt-Resurrecció/González Davies (2007) and by Angelelli (2004), who wrote the first study on the role of medical interpreters in hospital settings.

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