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Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Int J Radiat Oncol Biol >40 Gy depending on whether they had previously Phys 1997;37:853–863 discount 20 mg tadacip free shipping buy erectile dysfunction drugs uk. Presentation A 36-year-old multiparous Hispanic woman order tadacip with american express shakeology erectile dysfunction, 20- Discussion weeks pregnant purchase 20mg tadacip with mastercard erectile dysfunction statin drugs, presents in clinic with a complaint of a persistent, tender left breast mass of 3 weeks’ du- Mammography is both safe and useful in the evalu- ration. She is otherwise healthy, has no past history ation of the breast in pregnant women. The radia- of breast problems and no family history of breast or tion dose to the properly shielded fetus is only 0. Physical examination owing to the increased density of breast tissue in discloses a firm but not hard, slightly tender, mostly younger and pregnant women, mammography has discrete 2. A should be used in most cases, especially when the targeted left breast ultrasound is obtained. Differential Diagnosis The differential diagnosis includes cancer, fibroade- noma, lobular hyperplasia, lipoma, and (rarely) leukemia, lymphoma, sarcoma, neuroma, and tu- berculosis. Because the mass has persisted longer than 2 weeks, it requires further evaluation by completion of a modified triple test (addition of a needle biopsy to the clinical breast ex- amination and ultrasound). Alkaline mm macrolobulated hypoechoic mass, taller than phosphatase level is elevated, but a chest x-ray and 241 242 Case 55 low-dose bone scan are normal. A subsequent core 10% of women younger than 40 with breast cancer biopsy shows a high-grade invasive ductal cancer, are pregnanThat diagnosis. Breast cancers in pregnant women are histologically simi- Discussion lar to those in nonpregnant women, with 75% to Because of the tendency for delayed diagnosis of 90% being ductal cancers in either group. Many pregnancy-associated breast cancer, a high index of studies have shown decreased estrogen-receptor suspicion and an easy, rapid, “one-stop” method of positivity in pregnancy-associated cancers, possibly evaluating suspicious masses in the pregnant pa- due to receptor downregulation in pregnancy. Chest x-rays ciples used for nonpregnant patients, that is, aggres- are safe throughout pregnancy, but alkaline phos- sively for cure in most cases. Low-dose bone treatment for pregnancy-associated cancers, and the scans reduce the fetal radiation exposure by half choice of operation is based not only on the same (from 0. Thus, breast radiation during preg- nancy is contraindicated, and lumpectomy and ra- diation should be offered only if the radiation can Diagnosis and Recommendation be given postpartum (i. Because ter stages of the pregnancy), or if the radiation will this patient was already in her second trimester and be delayed by prior chemotherapy. Otherwise, a was likely to be a candidate for chemotherapy, she is mastectomy is typically chosen. Reconstruction af- offered either mastectomy or lumpectomy and radia- ter mastectomy should be delayed until after deliv- tion. With either approach, the standard axillary ■ Approach evaluation for invasive cancer is still two-level axil- Once thought to be rare, pregnancy-associated lary dissection. The accuracy and safety of sentinel breast cancer (breast cancer during, or within a year node biopsy in pregnancy is unknown, and preg- after, a pregnancy) is expected to increase in fre- nant patients are excluded from pending national quency as women delay childbearing until later in trials of this technique. Further, while technetium life, when the general risk of breast cancer begins to does not cross the placenta and the standard dose of rise. At present, breast cancer is the second most 1 mCi (or less) may give a very low dose to the fetus, common malignancy in pregnancy (after cervical isosulfan blue dye is a class C drug, and has not cancer), occurring in 1 in 5,000 deliveries. No data exist to compare patient outcomes after General anesthesia and breast operations are gener- chemotherapy in patients who received it during ally safe throughout pregnancy. Nevertheless, for pregnancy with patient outcomes for those in whom pregnancies more advanced than 32 weeks, consid- systemic treatment was delayed until after delivery. Anthracyclines are considered safer than general principles of operation during pregnancy alkylating agents in pregnancy. Taxane use was apply; the surgical team should be aware of the found safe in one case report. Recent studies of physiologic changes of pregnancy that can com- dose-dense schedules excluded pregnant patients. The pregnant patient should be ing increased plasma volume, decreased albumin given preoxygenation, antacids or acid-decreasing concentration, increased liver and kidney function, medications, fetal monitoring, rapid-sequence in- and decreased gastric motility, may affect chemo- duction with cricoid pressure, and elevation of the therapy dosing. Many drugs be decreased, and that lactation after radiation is of- typically used to treat chemotherapy side effects are ten difficult due to changes in the nipple and milk safe in pregnancy, including ondansetron, haloperi- ducts. The patient recovers well and is seen in consultation by The patient begins chemotherapy at 24 weeks’ ges- a medical oncologist who advises four cycles of tation. She receives two cycles, and then, following chemotherapy with doxorubicin (Adriamycin) and a rest period, delivers a healthy 7-pound baby girl by cyclophosphamide, followed by a taxane. The patient expresses an interest in possi- Discussion bly having another child in the future. Although all chemotherapy drugs are category D (ter- atogenic), these risks have generally been seen only in Discussion the first trimester; later in pregnancy they are surpris- ingly safe, with only a 1. In the only prospec- There is no evidence that therapeutic abortion im- tive trial of chemotherapy in pregnancy to date, proves the outcome in pregnancy-associated breast Berry, at the M. A large meta-analysis recently showed no tions were few, but did include preterm delivery link between previous abortion and subsequent in- (three cases), transient newborn tachypnea (two creased risk of breast cancer. The long- malities, is not recommended during pregnancy, 244 Case 55 and is usually stopped if a breast cancer patient Suggested Readings subsequently becomes pregnant. Oophorectomy has not been shown to improve the prognosis in Beral V, Bull D, Doll R, et al. Similarly, future rative reanalysis of data from 53 epidemiological studies, in- pregnancies do not appear to increase the likelihood cluding 83,000 women with breast cancer from 16 countries. J Clin On- gest that breast cancer survivors who subsequently col 1999;17:855–861. Management of general sur- become pregnant have a better 5-year survival than gical problems in the pregnant patient. A review of A 45-year-old asymptomatic woman with no signifi- her current mammogram, with magnification views, cant past medical history undergoes annual screen- demonstrates indeterminate microcalcifications in ing mammography and presents to your office with the upper outer quadrant of the right breast. Within these cat- egories, the percentages of cases with a surgical pathologic diagnosis of malignant involvement were as follows: benign calcification (0% malignant); in- determinate calcification (22%); malignant calcifica- tion (92%); smooth mass (1%); irregular mass (40%); architectural distortion (47%); asymmetric breast tissue (3%); smooth mass with calcification (0%); irregular mass with calcification (66%); architectural distortion with calcification (57%); and asymmetric breast tissue with calcification (29%). If this procedure is not available, then a nee- onstrates indeterminate calcifications in the upper dle-localized excisional biopsy should be performed. Magnification view demonstrates amorphous calcifications in a grouped distribution. The pathology demonstrates lobular car- Differential Diagnosis cinoma in situ and fibrocystic changes including Indeterminate microcalcification may be benign, sclerosing adenosis. Calcifications are seen in associ- though the likelihood of malignancy (noninvasive ation with benign fibrocystic changes. It does not form a mass, pro- hyperplasia, noninvasive carcinoma, and invasive car- duce nipple discharge, or routinely produce mammo- cinoma, and there may be a relationship between the graphic findings such as calcifications or architec- amount of calcification and the activity of the epithe- tural distortion. Stated an- breast cancer, albeit a higher rate than the general other way, 87% of patients at 10 years and 74% of pa- population.

Report of a case of verrucous epidermal nevus in a 20-year-old A report on the use of calcipotriol in the treatment of an patient that responded to acitretin 75 mg daily order discount tadacip on-line erectile dysfunction urinary tract infection. Eur J Dermatol Acitretin treatment of a systematized infammatory linear 2010; 20: 814–15 order cheapest tadacip erectile dysfunction drugs best. Renner R buy tadacip 20 mg visa erectile dysfunction treatment after prostate surgery, Rytter M, Sticherling A 9-year-old girl presented with asymptomatic linear papillo- M. After four treatment sessions, the lesion was almost completely The dose was slowly increased to 30 mg daily. After 3 months this level, the erythema had almost entirely resolved, and the of follow- up, the authors reported that the cosmetic and clinical hyperkeratosis was distinctly reduced. After 5 dose the infammatory and hyperkeratotic lesions had almost months of follow up, no recurrence had been observed. Treatment with dithranol resulted in complete relief from pru- Nevi that have infammatory, epidermolytic, acantholytic, or dys- ritus and clearing of all linear lesions, except for a small verrucous plastic features may respond more effectively to medical therapy band on the shin. There are few clinical data on the use of topical corticosteroids and their use appears to be empirical rather than evidence based; nevertheless, they are relatively cheap Pulsed dye laser for infammatory linear verrucous epi- and safe. All symptoms,  Topical calcipotriol/tacalcitol D including erythema, excoriation, granulation, and pruritus, disap-  Topical retinoids E peared, and a pale pigmentation remained. Ann Plast Surg 2001; resolution of pruritus and a signifcant improvement in roughness 47: 285–92. Infammatory linear verrucous epidermal nevus success- Successful treatment of a widespread infammatory ver- fully treated with methyl-aminolevulinate photodynamic rucous epidermal nevus with etanercept. She had a history failed the following modalities: clobetasol propionate in an of multiple therapies, including emollients, topical and intramus- occlusive dressing, intralesional triamcinolone acetonide, topical cular steroids, topical lactic acid, pimecrolimus cream, and tazarotene 0. She had minimal improvement with isotretinoin pionate, electrodesiccation, and oral antihistamines. After 1 month, the patient experienced disappeared, although small prurigo-like papules remained at the good initial improvement in pruritus and erythema. No recurrence was observed after a cept was increased to 50 mg twice weekly, which provided nearly follow-up period of 15 months. The histology of verrucous lesions demonstrates a highly characteristic cytopathic effect, with clarifcation of cytoplasm and nucleoplasm, and prominent keratohyaline granules. Flat warts and pityriasis Epidermodysplasia verruciformis in the setting of graft- versicolor-like lesions begin to appear in early childhood versus-host disease. J Am Acad Dermatol 2007; 58: patients begin to develop multiple cutaneous malignancies. J Am Acad Dermatol 2012; 66: phenotype in immunosuppressed individuals, especially in asso- 2292–311. Light-avoiding Surgical excision of malignant lesions E behavior and topical sunblock creams (sun protection factor >50) are indicated. Used as monotherapy, interferon-α has only a slight effect and is not recommended. J Eur Photodynamic therapy for human papillomavirus-related Acad Dermatol Venereol 2008; 22: 523–5. Maintenance treatment with 20 mg/day resulted yield excellent results in a case of epidermodysplasia verrucifor- in sustained remission. Epidermodysplasia verruciformis, unsuccessful therapeu- Dermatology 2003; 206: 148–52. Laser Favorable results are reported in some cases treated with therapy of recalcitrant warts proved to be effcacious in both imiquimod. Arch Dermatol 2012; For very widespread, constantly developing new lesions 148: 128–30. Wounds need to be evaluated and treated on 66 Epidermolysis bullosa a daily basis. Use of low concentration acetic acid or bleach in the bath water may also help control bacterial Lawrence A. Mepilex is a non- adherent, absorbent polyurethane foam pad that can be applied, removed, and reapplied to wounds with little discomfort, no trauma to the wound bed or surrounding skin, and no disruption of wound healing. Other non-adherent dressings, such as white petrolatum-impregnated gauzes, hydrogels, and foams, can be used and held in place with soft, roller gauze bandages or elastic tube dressings. Several trials have reported impressive results with Apligraf, a bilayered, tissue-engineered skin derived from neonatal foreskin that con- tains living keratinocytes and fbroblasts. Topical four major types according to the level of blister formation: antibiotics are routinely used, but should be rotated monthly to simplex or intraepidermal (’epidermolytic’), junctional or intral- avoid the development of resistant organisms. Cutaneous infec- amina lucida (‘lamina lucidolytic’), dystrophic or sublamina tions unresponsive to topical measures need to be treated with densa (‘dermolytic’), and Kindler syndrome or mixed. The systemic antibiotics, but the chronic use of systemic antibiotics is disease can involve the skin, mucosae, and internal organs. Avoidance of malnutri- dozen subtypes, resulting from more than 1000 documented tion depends on active and continuous nutritional support. In patients cutaneous manifestations, degree of morbidity, and risk for early who develop esophageal strictures, balloon dilatation, surgery mortality. Albumin avoidance of trauma, blister management, wound management, treat- should be monitored to assess the patient’s nutritional status. Severe been directed at identifying and treating the underlying cause of malnutrition can be treated with enteral feeding via gastros- disease with the goal of improving wound healing and preventing tomy tube if necessary. The punctured area should be covered with a Current therapies are focused on gene-, protein-, and cell-based topical antibiotic and a non-adherent dressing. There have been improvements in genetic manipula- Wound management comprises assessing the location and tion of keratinocytes ex vivo and of graft techniques in vivo. Gene characteristics of wound; cleansing with low toxicity solutions transfer of epidermal stem cells in combination with tissue engi- (e. J Am Acad day provided a unique forum for dietitians, doctors, nurses, physiothera- Dermatol 2008; 58: 931–50. Immunofuorescence antigen mapping is relatively inexpensive and simple to perform, requiring immunofuorescence transport media. It can reveal the Skin grafts C level of the split by defning its location relative to proteins Cultured keratinocytes C expressed at various levels of the basement membrane zone. Fibroblast cell therapy D Mutational analysis remains a superb research tool that lets us Amniotic cell membrane D determine the mode of inheritance, the precise site and the type of molecular mutation. However, it is not considered to be the Tissue-engineered skin (Apligraf) in the healing of frst-line diagnostic test. Nutritional support C The patients and their families considered that healing with the tissue-engineered skin was faster and less painful, and that quality A consensus approach to wound care in epidermolysis of life was improved, compared to healing with conventional bullosa. Apligraf in the treatment of severe mitten deformity asso- Wound care is the cornerstone of treatment for patients with ciated with recessive dystrophic epidermolysis bullosa. The list was refned and increased range of motion and have maintained web space grouped into four themes: treat cause; patient-centered concerns; separation for more than 12 months, improving the quality of local wound care; and develop individualized goals and plan of their life. Respondents also provided preventative and thera- Amniotic membrane grafting in patients with epidermoly- peutic pain management strategies, as well as dressing choices sis bullosa with chronic wounds.

They noted that the main determining factor for the For small verrucous epidermal nevi cheap tadacip 20mg free shipping erectile dysfunction yoga exercises, excision can be performed cosmetic result is thickness of the nevus order tadacip 20 mg overnight delivery erectile dysfunction education. However proven 20 mg tadacip erectile dysfunction in diabetes type 2, for larger lesions, or for those Laser therapy of verrucous epidermal naevi. For larger lesions shave excision can be performed, but recurrence A series of 43 patients (41 with verrucous epidermal nevi and often occurs. Soft, papillomatous lesions responded well to the have the beneft of being cost-effective and easily performed. Dermatol Surg 2004; 30: Review of the treatment modalities then available indicated that 378–81. After a single treatment, successful deeply, could result in hypertrophic scarring. Similar consider- elimination of the verrucous epidermal nevi was observed in 15 ations applied to cryosurgery. Ann Successful treatment of dark-coloured epidermal nevus Plast Surg 1992; 28: 292–6. A case report of treatment of a systematized epidermal nevus J Dermatol 1995; 22: 567–70. This cleared the nevus, but led Five darkly pigmented epidermal nevi were successfully cleared to extensive hypertrophic and keloidal scarring. Two patients subsequently had hypopigmentation at the Assessment of cryotherapy for the treatment of verrucous treatment site. Nine patients with verrucous epidermal nevi and two with  Systemic retinoids D extensive unilateral epidermal nevus were treated with cryosur-  Topical retinoids plus 5-fuorouracil E gery. Ten patients had their nevi treated successfully in two to fve  Photodynamic therapy E sessions, in which two cycles of open spray technique were used, 205 Systemic retinoids have been shown to reduce hyperkeratosis in very extensive and cosmetically troublesome lesions. However,  Systemic retinoids E long-term use is required if the beneft is to be maintained. The  Topical dithranol E topical combination of tretinoin and 5-fuorouracil has also been reported to achieve a signifcant improvement. A case of verrucous epidermal naevus successfully treated Topical calcipotriol for the treatment of infammatory with acitretin. Clin Dermatol 2003; ness of amniotic membrane grafting in promoting healing of 21: 278–82. Open or only partially healed erosions are best covered with polymyxin, bacitracin, or silver sulfadiazine and then covered with either petrolatum-impregnated gauze or non-adherent syn- thetic dressing. Tetracycline C Trimethoprim–sulfamethoxazole D The challenges of meeting nutritional requirements in Cyproheptadine C children and adults with epidermolysis bullosa: proceedings Isotretinoin C of a multidisciplinary team study day. Erratum in: N Engl J Med 2010; The effcacy of trimethoprim in wound healing of patients 363(14): 1383. Increased C7 deposition was observed at the did not achieve statistical signifcance. The six recipi- ents had substantial proportions of donor cells in the skin, and Chemoprevention of squamous cell carcinoma in reces- none had detectable anti-C7 antibodies. A initial study on 20 patients aged 15 years or 332-defcient, non-Herlitz junctional epidermolysis bullosa. Over a 10-year period, 23 ulcers were treated Correction of junctional epidermolysis bullosa by trans- using punch grafting without any complications or adverse plantation of genetically modifed epidermal stem cells. The ulcers had on average persisted 6 years before treat- Mavillo F, Pellegrini G, Ferrari S, Di Nunzio F, Di Nunzio F, Di ment. Thirty percent (n = 7) of the Ex vivo transduction of autologous epidermal stem cells with treated ulcers did not completely heal, but did show improve- a normal copy of the defective gene, followed by reconstitution ment. The recurrence rate after 3 months was 13% (n = 2), and of the patient’s skin with epithelial sheets that were grown from was a result of renewed blistering. Punch grafting can be used as these genetically corrected cells, kept the epidermis frmly adher- a frst-line treatment in small persistent ulcers in patients with ent and stable for the duration of follow-up (1 year). Risk of squamous cell carcinoma in junctional epider- Treatment of epidermolysis bullosa simplex with tetracy- molysis bullosa, non-Herlitz type: report of 7 cases and a cline. J Am Acad A number of patients using tetracycline were observed over a Dermatol 2011; 65: 780–9. A commonly used initial regimen is systemic corticosteroid with either mycophenolate mofetil or dapsone t 67 Epidermolysis bullosa or both as a corticosteroid-sparing agent. For adult patients without signifcant medical problems, a combination of oral acquisita prednisone (1 mg/kg daily), mycophenolate mofetil (1–2 g daily), and dapsone (100–200 mg daily) can be started. Because of its rarity, no well-controlled clinical trial has been performed Lawrence S. The following therapeutic guidelines are derived mainly from case reports of small groups or single patients. Cyclosporine (5–9 mg/kg daily) has been shown to be benefcial in reducing blister formation and speeding up healing. In addition, extracorporeal photochemotherapy has been used successfully in some patients. At present the high cost and diffculty of obtaining insurance company approval are the major hindrances to the use of rituximab. In addition to medical treatments, patients with this disease should be instructed to avoid physical trauma as much as possible. Vigorous rubbing of their skin and the use of harsh soaps and hot water should also be avoided. Patients should be instructed to care for open wounds promptly and to recognize local skin infec- tion and seek medical attention when infection occurs. The disease primarily affects elderly individuals and immunofuorescence, respectively, to detect IgG or occurs predominantly at trauma-prone skin areas (the non- IgA class skin basement membrane-specifc infammatory mechanobullous scarring subset) or widespread autoantibodies skin areas (the generalized infammatory non-scarring subset). Epidermolysis bullosa acquisita, especially the non-infammatory Identifcation of the skin basement-membrane autoanti- mechanobullous subset, is characteristically very resistant to con- gen in epidermolysis bullosa acquisita. N disease associated with autoantibodies that target skin compo- Engl J Med 1984; 310: 1007–13. However, no target- rescence detects IgG circulating autoantibodies bound to the specifc treatment is currently available. Thus the presently avail- dermal side of salt-separated normal skin substrate in about 50% able non-target-specifc immunosuppressants not only reduce the of patients with this disease. IgA-mediated epidermolysis bullosa acquisita: two cases and review of the literature. However, IgA-mediated disease has a lesser tendency to regimen of prednisolone (25 mg/day) and dapsone (25 mg/day) form scar and is more responsive to dapsone treatment. This case illustrates the usefulness of mycophenolate Infammatory bowel disease, particularly Crohn’s disease, is mofetil in childhood-onset disease. All patients should be questioned for symptoms of infammatory Mycophenolate mofetil in epidermolysis bullosa acquis- bowel disease. Kowalzick L, Suckow S, Zuiegler H, Waldmann T, Pönni- intestinal work-up is indicated. The clinical improvement was associated with a Invest Dermatol 2002; 118: 1059–64.

The Duty of Care is also owed by the treating institution to provide adequate and trained hands and all necessary latest functioning equipment discount 20mg tadacip free shipping impotence is a horrifying thing. Institutional vicarious liability can arise for the negligent acts of its employees and also through a failure to provide sufficient staff or equipment order tadacip on line erectile dysfunction 40s. Breach of duty of care may be deemed to have occurred due to the following acts of omission or commission on the part of the anesthesiologist and is punishable under Sec cheap tadacip online visa erectile dysfunction free samples. Nondisclosure of inherent or potential dangers involved during or after the chosen technique of anesthesia. A reasonable patient would have deferred operation if he had known of the risks involved. Failure to fulfill the duty of care occurs if a patient suffers damage due to dereliction in the duties by the concerned doctors; a legal action may be initiated against them and the institution any time within the period of limitation prescribed by the consumer or civil courts of jurisdiction. Immunity to breach of duty is considered when a doctor acts as a good samaritan and helps an injured person during an emergency, he/she is immune to breach of duty. But if there is an action of omission or commission by the doctor, which is acceptable only by a minority of anesthesiologists, it may be construed as a breach of duty. Standard of Care Standard of care is defined as the level at which the average, prudent and similarly qualified providers in a given community, would manage the patient’s care under 18 Yearbook of Anesthesiology-6 the same or similar circumstances. The standard of care varies with the level of healthcare facility, the quality of work and expertise of the health workers. In far-flung places or level-1 hospitals, where proper infrastructure for administration of anesthesia is not available, a lower standard of care is acceptable as per the ‘Locality rule of law’. However, since most of the world has now become a global village, the locality rule may no longer be acceptable in many places. Hence, the doctors are expected to demonstrate the skills established by their respective specialties according to the established ‘National Standard of Care’. In cases of medical negligence, the courts have set a pragmatic standard of care which is flexible to the extent that it mirrors developments within medical knowledge and caters for alteration in medical practices. It also recognizes the fact that medical treatment is full of risks and the desired outcome may not be achieved. They may not be aware of the latest developments but they are expected to follow the protocols of the institution. This was a government initiative appreciated by all the anesthesiologists especially those who worked as freelance practitioners in small nursing homes, where owners of the nursing homes provided neither an anesthesia machine nor the patient monitors for the operation theaters. Documenting the standard of care: Anesthesia record is the primary document, which reveals the standard of care rendered by an anesthesiologist in case legal disputes arise. The acceptable standard of care in anesthesia in most of the countries in the world is determined by the medical societies practicing the specialty. Deviations from standard of care determines the negligence claims and good documentation helps to demonstrate in disputed cases whether the standard of care was breached or not. If the breach results in an identifiable injury then the damages [as monetary compensation] may be granted to the injured patient who files a complaint. Failure of standard of care: A doctor is judged by the standard of care prevalenThat the time of occurrence of an adverse event and not by that presenThat the time of trial which could be many years later. Breach of standard of care: Proof of breach of standard of care is necessary for award of compensations in claims for negligence or malpractice. It may not be advisable to rush to attendants to tell what happened without knowing the cause or the possibilities. Surgeon and the anesthesiologist must ask for cross-consultation from other specialties as necessitated by the event and must discuss about the cause and the possible outcomes. If the critical event happens at induction of anesthesia which is serious and resuscitation takes more than a few minutes to achieve the desired response but the patient’s response to medical treatment is slow, then the surgical team should consult the family members. Documentation The anesthesiologist and the operating surgeon must consult each other and together record correct timing of all intraoperative adverse events. If there is any difference of opinion it must be solved inside the operation theaters itself and not in the court after few years. The surgical and anesthetic document should not have any illegible writing or overwriting on the error. It is recommended to cross it with a single line and enter the correct time, date with signatures and mention the reasons for the correction. The anesthesia chart should not be altered as it rises suspicion about hiding the truth and there have been cases where handwriting experts have been consulted in cases of erasure or overwriting on the chart. The patient can be safely discharged if he has an Aldrete Score of 12/14 based on his activity, respiration, circulation, consciousness and oxygen saturation. The anesthesiologist should not undertake the next case in hurry without proper handover to the postoperative nurse/assigned doctor. Care of a Patient after the Bad Outcome The doctors should maintain good contact with the family members and allow them to vent their anger and take care of the patient continuously. They 20 Yearbook of Anesthesiology-6 should never hand over the patient to others and leave the scene but involve other consultants for their opinion regarding the management. The family members should be contacted at regular intervals and the progress of the patient should be communicated by a designated consultant to avoid different versions of the progress given by junior nurses or paramedical staff. The patient may be shifted to a higher center if there is a necessity, and follow up with the patient and family may be maintained to give them solace and to gain sympathy of the patient’s attendants. If the bad outcome is due to unknown cause, the insurance company must be notified and the expert opinion must be sought. Displays on monitors should be believed and confirmed instead of finding fault with them. Time should be spared by all concerned to listen to the patient or his family members. The Tort of negligence requires a complainant to show first that a duty of care was owed to him by the doctor and there was foreseeability of harm by the doctor and there was breach of care, which resulted in injuries. To determine the quantum of compensation to be awarded to the complainants, the courts determine the link between the breach of duty and the injury. The doctor is held guilty of negligence when even though he doesn’t desire to produce the adverse events, he acts in an indifferent or careless way in attending to the patient. A common example of an inefficient monitoring by an anesthesiologist is of indulgence in chatting and tweeting on the social media about the same patient a little while before a major adverse event happened to him, which proved his negligence. This involves looking at the consequences of the act and awarding of financial compensation to sufferers general damages for pain, suffering, anxiety and special damages for medical expenses, future expenses, loss of wages and rehabilitation costs. Law determines the liability of doctors through the following sources: Testimony of witness of the adverse event:Hence a copy of the document containing the testimony must be acquired soon after the accident by the anesthesiologist. Testimony about the practice pattern of the anesthesiologist such as preuse machine checks is also very useful for decision making by the courts. Expert witness testimony: Judges may be laymen in medicine but there are experts who assist them to reach a decision based on their inputs and results of their investigations.