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Staying human in the medical family: the family members to program orientation sessions and retreats unique role of doctor-parents 400 mg trental fast delivery. Family-friendly programs often have an edge in recruiting and retaining ex- cellent residents who order trental 400mg mastercard, in turn trental 400 mg generic, contribute to the goals of the department in a spirit of collegiality buy 400 mg trental with visa, community and respect. Thus physical As a rule, they are energetic, hard-working, enthusiastic, intel- activity become a low priority, and a lack of healthy exercise ligent and self-disciplined. They have learned to delay gratifca- erodes one’s energy level and sense of well-being even more. They are idealistic, and most come to medicine because they are inspired to contribute Emotional and physical fatigue lead to behavioural changes. Decreased interest in activities that were once enjoyed during free time leads to social withdrawal and personal isolation. However, the profession of medicine is demanding, and it is Relationships with family and friends are compromised, and diffcult to put limits around its practice. Poor constant exposure to suffering, heavy workloads, long hours, coping strategies that are adopted might include the increased time pressures, physical and mental demands, and a lack of intake of caffeine and alcohol, or the use of illicit drugs. Physicians are acutely Faced with some or all of these effects, one might experience aware of the distress of others but are often less attentive to at the same time a reduced sense of accomplishment and the stress and fatigue that they experience themselves. It is easy to lose sight of one’s accomplishments caring for others often leads to neglect of oneself. This is the sign of We know that physicians, as a group, are well informed with signifcant stress. We also know that when physicians are overwhelmed by the demands Given that the demands of the profession are ever present, of their profession, they are vulnerable to neglecting those what is the solution? It requires, frst and foremost, awareness of the risks mises not only the physician’s health, but his or her ability to that will be present and deliberate attention to measures of continue to provide care for others. Physicians’ self-care presents a perfect opportunity to practise preventative care. When self-care is neglected When a physician becomes immersed in his or her work to the Solutions: Think “self-care” exclusion of self-care, a cascade of stress-induced symptoms In The 7 Habits of Highly Effective People, Steven R. A feeling of being chronically overwhelmed a compelling case for what he describes as the “Principles of leads to frustration and irritability. The physician may become Balanced Self-Renewal,” which he describes as “preserving and prone to emotional outbursts, or may be tearful at work in enhancing the greatest asset you have–you. He or she may take domains that require attention in self-care: physical, emotional, less pleasure in activities that were once much enjoyed. Effective self-care requires consideration meantime, a denial of the signifcance of these symptoms and of these four domains, and taking control of the things that the vulnerability they reveal can lead the physician to take on can be controlled. In caring for one’s physical self, planning for healthy eating is Physical symptoms can include intermittent headache, gastro- a good place to start. We can decide what to eat and when to intestinal complaints, and poor sleep, often with a tendency to eat. Taking the time to purchase healthy food and preparing wake between 2:00 and 4:00 a. These symptoms can be ac- meals that are nutritious will lead to an improved sense of companied by a change in appetite and a slide into poor eating energy and well-being. Planning the use of time away from the habits, for example by relying on fast-food outlets rather than workplace, so that exercise is a regular part of one’s routine, is taking the time to prepare healthy meals. Regular exercise is The tools for self-care are evident to most physicians: their therefore one of the best self-care tools for reducing stress. However, although they apply this knowledge on a daily in the activity and make a commitment to participate regularly. Although these strategies that self-care, and employing the tools necessary to attend to for self-care are simple and lie within our control, they are one’s own needs, is not only wise: it is essential to sustain an frequently forgotten when we are busy. Value the mutual support that arises from collegial relation- Chicago: American Medical Association. Learn strategies such as relaxation techniques to help build the emotional resilience that will be needed in times of stress. Tools for cognitive well-being include strategies that use the intellect to stimulate thinking, and hence one’s outlook, in positive ways. Writing down your feelings can help you to slow down and refect on your life and practice. Learning to set limits on your time and to use time wisely is a cognitive strategy to deliberately attend to self-care. What is central to stress management is the atten- This chapter will tion we give ourselves in the present moment. Do we pay attention to each bite of our breakfast, or do we hurry it down with gulps of coffee while scanning our emails, half-listening to the radio in the background? Case Do we carefully listen to our patient’s complaints, or are we A third-year resident has suffered from anxiety throughout mostly focused on getting through the patient list in time their medical training. But competent than their peers has made the anxiety particularly mindfulness is not something foreign; it’s a capacity we often acute. It is both the ability to focus on this text as we read it, and purging as a way to cope with stress. The resident hides the aspect of mind that notices when our attention has drifted this behaviour from others, as they consider the anxiety away. Mindfulness is not thinking: it’s more like the awareness and bulimia a further sign of inadequacy. Deepening our resident does enter an introductory six-week mindfulness mindfulness through practise is a way of inoculating ourselves program offered by the medical school. Introduction The relaxation response The road to independent medical practice is long, demanding We can’t avoid stress: stress is triggered by change, and life and fraught with stress. When residents eventually largely determines how much they enjoy this period of their fnish their training, new challenges will come. Many manage the inevitable stress of their residency can prepare for an exam by studying, we can prepare for years by focusing on the “light at the end of the tunnel,” thus the inevitable presence of stress by practising being present. A considerable body of ceptance the workload increases: “Oh well, it will be different research demonstrates that mindfulness techniques produces in residency; I’ll be making money and can fnally focus on my a relaxation response that has the opposite effect of the stress real vocation. Postponing certain choices today for the promises of tomor- row often makes sense. If we don’t crack the books until the Refection: Practising mindfulness in daily life week before our fellowship exams, well, we know how that • Allow yourself a few mindful breaths in the will turn out. But, while planning for the future is helpful, liv- morning before you get out of bed. Planning for the • Try preparing and eating your breakfast quietly, future means orienting our actions so that they contribute to a without distraction, once a week. Managing stress with mindfulness • Let the world wake you up: when you notice a This habit of living for tomorrow is a fawed coping strategy: it phone ring, a door slam, and so on, take a is based on the false premise that tomorrow is more real than moment to sense where you are and how you today. Clearly, the content of this moment is always • Sign up for a class on meditation, yoga, tai chi, shifting and new; however, whatever happens, we experience it etc. Cultivating mindful- weeks to delay, and eventually eliminate, the binging ness through regular formal practise extends the habit of episodes. The resident also begins to question these nega- being present into our daily activities. Try this for the next tive self-judgments and seeks counselling for the eating few breaths. The resident discloses abdomen moving in and out with each breath and stay with these challenges and fears to a close friend and feels less that sensation. Before long your mind will likely drift off into isolated and less anxious about life in general. The resident thoughts about this experience, or about something completely plans to continue with regular meditation. When you notice that your mind has drifted into thinking, let go of the thoughts and come back to the sense of breathing. It’s simple and yet Self-acceptance diffcult to stay present: it takes discipline to train our minds As we become mindful of uncomfortable feelings and the to simply be in the moment when our tendency is to want to habitual patterns they trigger, we may become self-critical: control it. Cranky Making friends with fear or tired, sexually restless or serene, what matters is that we Stress arises from our attempt to create certainty in an uncer- can deepen our capacity to notice, and to be with, whatever tain world. Such activities might take the edge off ing of our quirks and foibles, we also naturally become more our anxiety momentarily, but when anxiety has the upper hand accepting of others.

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When effective buy trental 400mg online, these regulatory mechanisms result in the maintenance of a stable body weight (Jequier and Tappy proven 400mg trental, 1999) 400 mg trental fast delivery. Otherwise generic trental 400mg free shipping, individuals with higher efficiency would require less energy for equal energy expenditure than persons with lower efficiency. The experimental data supports the notion that differ- ences in efficiency of energy utilization among healthy individuals living under similar conditions fluctuate within a narrow range (James et al. Body weight can be remarkably stable in many healthy adults, demon- strating the human potential for maintaining energy balance and stable body composition in spite of conditions that have promoted the recent secular trends in increasing body weights. Maintenance of stable body weight and composition are affected by genetic factors, energy intake, and diet composition, as well as by other environmental factors (Hill and Peters, 1998). Environmental conditions favoring high energy consump- tion and low physical activity can overwhelm these mechanisms and lead to positive energy balance, resulting in body fat accumulation and weight gain until another state of weight maintenance becomes established. Thus, weight gain and obesity can be seen as a form of adaptation that brings about a new steady state (Astrup et al. A more practical defini- tion, applied to the study of energy requirements, would be the ability to compensate for changes in energy (energy intake, expenditure, or bal- ance) without any discernible detriment to health. Although the concept applies both to increases and decreases in energy intake or energy expenditure, a focus of controversy has been its application to the definition of energy needs in poor areas of the world. In studies that specifically attempted to assess whether some adaptive mecha- nism may permit those populations to subsist with lower than predicted energy intakes, no reduction in weight-adjusted basal metabolic rates could be detected (Soares et al. Reports on the ethnic and gender differences in energy efficiency have yielded conflicting results, but the overall contributions such differences can make toward the main- tenance of energy balance appears to be small (Soares et al. However, most overfeeding studies show that over- eating is accompanied by substantial weight gain, and likewise reduced energy intake induces weight loss (Saltzman and Roberts, 1995). Accommodation The term accommodation was proposed to characterize an adaptive response that allows survival but results in some more or less serious conse- quences on health or physiological function. By reducing growth rate, chil- dren are able to save energy and may subsist for prolonged periods of time on marginal energy intakes, though at the cost of eventually becoming stunted. This can result in reduced productivity of physical work or in decreased leisure physical activity, which in children is important for behavioral and mental development (Twisk, 2001). However, the measurements were obtained from men, women, and children whose ages, body weight, height, and physical activities varied over wide ranges, so they provide an appro- priate base to estimate energy expenditures and requirements at different life stages in relation to gender, body weight, height, age, and for different activity estimations. A few age groups are underrepresented in the data set and interpolations had to be performed in these cases. This data set, used to estimate the current energy recommendations, can be used to refine other existing communicated recommendations or guidelines developed by other orga- nizations and agencies. Subjects were required to be healthy, free-living, maintaining their body weight, and with measured heights and weights. Exclusion crite- ria included undernutrition, acute and chronic diseases, underfeeding and overfeeding protocols, and lifestyles involving uncommonly high levels of physical activity (e. There are 407 adults in the normative database (Appendix Table I-3), 169 men and 238 women. Among the men whose ethnicity was reported, there are 33 Caucasians, 7 African Americans, and 2 Asians, and among the women there are 94 Caucasians, 13 African Americans, 3 Asians, and 3 Hispanics. For the 100 adults for whom data were provided on occupation, the most com- monly reported types of occupations were offices workers, followed by teachers and students, scientists, medical workers, active occupations (e. The database for normal-weight children (n = 525) (Appendix Table I-2) includes 167 boys (73 Caucasians, 13 African Americans, 4 Hispanics, and 62 American Indians) and 358 girls (197 Caucasians 58 African Ameri- cans, 20 Hispanics, 10 Asians, and 60 American Indians); ethnicity was not provided for 15 boys and 13 girls. There were insuffi- cient data to address pregnancy and lactation in overweight and obese women. The database for overweight and obese adults contains information on 360 individuals—165 men and 195 women (Appendix Table I-7). Among the men whose ethnicity was reported, there are 22 Caucasians and 21 African Americans; among the women there are 51 Caucasians, 34 African Americans, and 5 Hispanics. The majority of the data come from studies conducted in the United States and the Netherlands; the rest are from studies conducted in the United Kingdom, Sweden, and Australia. For those 34 indi- viduals for whom an occupation was given, the most common types were office workers, followed by medical personnel, homemakers, active occu- pations (e. The database for overweight and obese children (n = 319) (Appendix Table I-6) includes 127 boys (33 Caucasian, 20 African-American, 2 His- panic, and 71 American Indian) and 192 girls (63 Caucasian, 48 African- American, 6 Hispanic, 68 American Indian, and 1 Asian; ethnicity was not provided for 1 boy and 6 girls. As in any realistic statistical modeling activity, the balance is between fitting the data and fitting the phenomena, while making opti- mal use of the available data. The analyses were restricted to include individuals within the specific ranges of body sizes and excluded individuals who were identified as being full-time in physical training. An additive model was chosen as the default, with the relative contri- butions of height and weight kept constant for each gender. Various transfor- mations of the data and the inclusion of multiplicative terms were explored, but none significantly improved how well the model described the data. During the exploratory phase, evaluations of alternative models were based on the magnitude of residual error and examination of residual plots. These residual plots showed that while errors are not constant over the whole range of the variables, there is no simple pattern. Since nonlinear regression is an iterative approach, the influence of varying the starting point was investi- gated and was found not to be a problem. The standard errors of the coefficients were estimated asymptotically; for a sample of the fits esti- mates were determined by jackknife techniques; these were found not to change the conclusions. Gender-specific equations were found to be unnecessary in children less than 3 years of age. Therefore, values for individual standard deviations are recom- mended as 70 percent of the observed standard error of fit (Table 5-14). The data were fitted to this equation using nonlinear regression and the Levenberg-Marquardt method for searching for convergence based on minimizing the sum of residuals squared. For each fit an R-squared was calculated as the ratio of the explained sum of squared error to the total sum of squared error, and asymptotic standard errors of the coefficients were calculated. The energy requirements of infants and young children should balance energy expenditure at a level of physical activity consistent with normal development and allow for depo- sition of tissues at a rate consistent with health. This approach requires knowledge of what constitutes developmentally appropriate levels of physi- cal activity, normal growth, and body composition. Although the energy requirement for growth relative to maintenance is small, except during the first months of life, satisfactory growth is a sensitive indicator of whether energy needs are being met. To determine the energy cost of growth, the energy content of the newly synthesized tissues must be esti- mated, preferably from the separate costs of protein and fat deposition. The brain, liver, heart, and kidney account for most of the basal metabolism of infants. There is also an increase in O2 consumption during the transition to extrauterine life. After birth, the O2 consumption of these vital organs increases in propor- tion to increases in organ weight. The high variability is attributable to biological differences in body composition and technical differences in experimental conditions and methods. Significant differences between breast-fed and formula-fed infants have been reported at 3 and 6 months (Butte, 1990; Butte et al. Schofield compiled approximately 300 measurements from Benedict and Talbot (1914, 1921), Clagett and Hathaway (1941), Harris and Benedict (1919), and Karlberg (1952) to develop predictive models based on weight and length (C Schofield, 1985). These observations support the view that some of the observed energy expenditure is due to the metabolic costs of tissue synthesis. The amount of energy re- quired to maintain normal body temperature is greater at lower than at higher temperatures (Sinclair, 1978). The neonate responds to mild cold exposure with an increase in nonshivering thermogenesis, which in- creases metabolic rate and may be mediated by increased sympathetic tone (Penn and Schmidt-Sommerfeld, 1989). Increased oxidation of fatty acids in brown adipose tissue located between the scapulae and around major vessels and organs of the mediastinum and abdomen is thought to make the most important contribution to nonshivering thermogenesis in infants (Penn and Schmidt-Sommerfeld, 1989). Shivering thermogenesis occurs at lower ambient temperatures when nonshivering thermogenesis is insuf- ficient to maintain body temperature. Much understanding of the energy cost of growth has been derived from preterm infants or children recovering from malnutrition (Butte et al. In practicality, the energy cost of growth is an issue only during the first half of infancy when energy deposition contributes significantly to energy requirements. In this report, the energy content of tissue deposition was computed from rates of protein and fat deposition observed in a longitudinal study of infants from 0. The energy content of tissue deposition (kcal/g) derived from the above study was applied to the 50th percentile of weight gain published by Guo and col- leagues (1991) as shown in Table 5-15 for infants and children 0 through 24 months of age.

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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www proven trental 400mg. See also Partner services Central nervous system demyelinating education of safe trental 400mg, 97 generic trental 400 mg overnight delivery, 98 disorders effective trental 400mg, 32 vaccination, 54, 57-58, 62, 93, 117, Chicago, 28, 116, 121 119-120 Childhood Immunization Initiative, 126 Correctional facilities. See also Liver cancer and discrimination liver cirrhosis age at exposure and, 19, 22, 46, 51, 82- Drug treatment programs and facilities. See also Illicit-drug users 83, 113, 117, 118, 156 knowledge of, 80, 83, 89 educational programs on viral hepatitis, 8, 88-89, 95-96, 100, 176 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See Illicit-drug users Infectious Diseases program, 59 Exposure routes knowledge and awareness, 95 E sexual, 1, 23, 44, 72, 84, 119-120 unsafe vaccine injections, 24 Economic issues. See also Funding; Insurance coverage screening and testing, 27, 161-162, 163 F vaccination, 54, 57-58, 117-119, 124, 137-138 Federal Employees Health Benefts Program, Educational programs. See also Knowledge 5, 13, 130, 148, 172 and awareness of chronic hepatitis Florida Hepatitis Prevention Program, advocacy efforts, 153-154 186-187 for alternative-medicine professionals, Food and Drug Administration, 109 86, 87, 89 Foreign-born populations. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also Vaccination for also Liver cancer and liver cirrhosis Hepatitis B; specifc populations and public vaccine programs and insurance, services 128-132 acute infection, 1, 19, 23, 27, 34, 48, racial/ethnic differences, 27, 29 50, 59, 70-71, 99, 117, 118, 119, reactivation, 162 120, 121, 125, 161, 189 registries of immunization, 126-127 adults, 27, 47, 117-125, 132 risk factors, 27 at-risk populations, 1-2, 21-22, 27, 81- screening and testing, 5, 8, 13, 14, 23, 82, 120-125 27, 47, 48-49, 51, 81, 82-83, 86, 90, case defnition, 48, 50, 51, 52 91, 124-125, 152, 156-157, 160-162 causative agent, 19, 21 stigma/discrimination, 23, 91-92 children, 23, 25, 30, 47, 116-117, surveillance, 44, 46, 47, 48, 50, 51, 52, 128-132 59-60, 61, 64, 71 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See Liver cancer referral for medical management, 148 and liver cirrhosis screening, testing, and counseling, 14, High-risk populations. See At-risk 62, 83, 85, 86, 94, 148, 156-157, populations Hispanics, 2, 10, 27, 30, 93, 116, 121, 159, 158, 162, 163, 179 stigmatization and discrimination, 24, 168-169, 184-185 85 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also Foreign-born Insurance coverage populations gaps and barriers, 11, 134-135, 170 Immunization. See also Educational surveillance, 62 programs vaccination, 121-124, 157, 185 age and, 93 viral health services, 6, 16, 149, 184-186 asymptomatic infected individuals, 1, 3, Incidence of hepatitis. See Prevalence and 24, 26, 27, 50, 51, 90 incidence of hepatitis at-risk populations, 3, 4, 8, 9, 13, 34, Infants. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See Viral hepatitis services applications of data from, 41, 42, 43-46 Sexual exposure to hepatitis, 1, 23, 44, 72, at-risk populations, 2, 4, 6, 7, 32, 61-62, 84, 113, 119-120 67, 68, 71-72 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Request reprint permission for this book Copyright © National Academy of Sciences. The members of the Committee responsible for the report were chosen for their special competences and with regard for appropriate balance. N01-0D-4-2139 between the National Academy of Sciences and the National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: x Leslie Biesecker, National Institutes of Health x Martin J. Blaser, New York University Langone Medical Center x Wylie Burke, University of Washington x Christopher G. Chute, University of Minnesota and Mayo Clinic x Sean Eddy, Howard Hughes Medical Institute Janelia Farm Research x Elaine Jaffe, National Cancer Institute x Brian J. Schwartz, University of Washington Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Dennis Ausiello, Harvard Medical School, Massachusetts General Hospital and Partners Healthcare and Queta Bond, Burroughs Welcome Fund. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the authoring committee and the institution. We are grateful to those who attended and participated in the workshop “Toward a New st nd Taxonomy of Disease,” held March 1 and 2 , 2011 (Appendix D) and those who discussed data sharing with the Committee during the course of this study. Kelly, Head of Informatics and Strategic Alignment, Aetna x Debra Lappin, President, Council for American Medical Innovation x Jason Lieb, Professor, Department of Biology, University of North Carolina at Chapel Hill x Klaus Lindpaintner, Vice President of R&D, Strategic Diagnostics Inc. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease Summary The Committee’s charge was to explore the feasibility and need for “a New Taxonomy of human disease based on molecular biology” and to develop a potential framework for creating one. Clearly, the motivation for this study is the explosion of molecular data on humans, particularly those associated with individual patients, and the sense that there are large, as-yet- untapped opportunities to use these data to improve health outcomes. The Committee agreed with this perspective and, indeed, came to see the challenge of developing a New Taxonomy of Disease as just one element, albeit an important one, in a truly historic set of health-related challenges and opportunities associated with the rise of data-intensive biology and rapidly expanding knowledge of the mechanisms of fundamental biological processes. Hence, many of the implications of the Committee’s findings and recommendations ramify far beyond the science of disease classification and have substantial implications for nearly all stakeholders in the vast enterprise of biomedical research and patient care. Given the scope of the Committee’s deliberations, it is appropriate to start this report by tracing the logical thread that unifies the Committee’s major findings and recommendations and connects them to its statement of task. The Committee’s charge highlights the importance of taxonomy in medicine and the potential opportunities to use molecular data to improve disease taxonomy and, thereby, health outcomes. Taxonomy is the practice and science of classification, typically considered in the context of biology (e. The Committee envisions these data repositories as essential infrastructure, necessary both for creating the New Taxonomy and, more broadly, for integrating basic biological knowledge with medical histories and health outcomes of individual patients. The Committee believes that building this infrastructure—the Information Commons and Knowledge Network—is a grand challenge that, if met, would both modernize the ways in which biomedical research is conducted and, over time, lead to dramatically improved patient care (see Figure S-1). Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease ʹ Figure S-1: Creation of a New Taxonomy first requires an “Information Commons” in which data on large populations of patients become broadly available for research use and a “Knowledge Network” that adds value to these data by highlighting their interconnectedness and integrating them with evolving knowledge of fundamental biological processes. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease ͵ The Committee envisions this ambitious program, which would play out on a time scale of decades rather than years, as proceeding through a blend of top-down and bottom-up activity.

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Habitat modification in wetlands can eliminate or reduce the risk of disease best trental 400 mg, by reducing the prevalence of disease-causing agents generic 400 mg trental, vectors and/or hosts and their contact with one another purchase trental 400mg without a prescription, through the manipulation of wetland hydrology proven 400mg trental, vegetation and topography and alterations in host distribution and density. Movement restrictions of animals and people, usually imposed by government authorities, can be an effective tool in preventing and controlling disease transmission through avoiding contact between infected and susceptible animals. Complete eradication of a disease requires a thorough understanding of its epidemiology, sufficient political and stakeholder support and thorough resourcing and is thus rarely achieved! Elimination of disease from an area is a more likely outcome although this depends on measures to prevent re-emergence being taken. Sanitation measures involve preventing animal contact with physical, microbiological, biological or chemical agents of disease, which are often found in wastes, and maintaining clean, hygienic conditions. Inadequate sanitation is a major cause of disease worldwide and simple measures for improving sanitation are known to have significant beneficial impacts on public and animal health. Disinfection prevents the mechanical transmission of disease agents from one location to another by animals and inanimate objects, by eliminating many or all pathogenic microorganisms (except bacterial spores) on inanimate objects so that they will no longer serve as a source of infection. Disinfection following fieldwork prevents transfer of infection on fomites such as boots and clothing. Measures taken to prevent a disease outbreak For public health and biosecurity reasons, people working in wetlands should maintain high standards of sanitation and hygiene, and avoid direct contact with human and animal faeces, solid wastes, domestic, industrial and agricultural wastes [►Section 3. Effective sanitation and hygiene can be achieved through engineering solutions (e. Livestock housing should be regularly cleaned and disinfected and waste and clean water should be separated and safely stored. Waste materials from captive animals should be properly processed and disposed of. Cleaning is a necessary first step that allows the subsequent disinfecting agent to come into direct contact with pathogens on the surfaces of an object. Some viruses, bacteria and other infectious agents can persist in the environment for protracted periods. Disinfection is only practical for circumstances in which the pathogen or disease transmission occurs in a very limited area. The appropriateness of disinfectants will be informed by information on the presence of non-target species and other potential environmental impacts, particularly any adverse effects on wetland ecosystem function. Disinfection for wildlife disease situations is often difficult and likely to be most effective where wild animals are concentrated, such as at artificial feeding or watering sites. Measures taken during a disease outbreak During a disease outbreak, it may be necessary (if practical) to disinfect the local environment to prevent recurrence. Procedures are generally similar, however, the nature and infectivity of the pathogen will affect the protocols employed. For example, chytrid fungus and foot and mouth disease virus will require very different procedures for decontamination. As a consequence, disinfection of a disease outbreak site should always be conducted under the guidance of disease control specialists. From the above, the following should be done, as appropriate: during disinfection activities, easily cleaned protective clothes such as waterproof coveralls and rubber boots and gloves should be worn, and all clothes should be thoroughly washed after use and before leaving the outbreak area. If possible, personnel should wash their hair before leaving the area, and always before going to other wetland areas. Personnel handling potentially infectious agents should not work with similar species or those susceptible to disease for at least seven days after participating in disease control activities. Disinfection processes require a suitable disinfectant, containers for the solution once it has been diluted to the appropriate strength and a suitable method for its application. Vehicles and boats with pumps and tanks can be used to store and dispense disinfectant. All vehicles should be cleaned and disinfected on entering and leaving an outbreak area. Brushes, buckets, and containers that can be used to clean and disinfect boots and pressure sprayers that can be used to dispense the disinfectant are also required. Disease control specialists should advise on the most appropriate type of disinfectant and its application in wetland settings. Physical and chemical factors: temperature, pH, relative humidity, and water hardness (e. Organic and inorganic matter: serum, blood, pus, faeces or other organic materials can interfere with the effectiveness of disinfectants. Duration of exposure: items must be exposed to the chemical for the appropriate contact time. Disease control contingency plans should identify readily available sources of supplies and equipment needed for disinfection activities in case of an outbreak. Wetland managers, particularly those caring for housed livestock, should consider keeping a supply of disinfectant for general use. Health and safety risks of using chemicals Disinfectants may be toxic to humans as well as animals and plants, and therefore all chemicals should be used in accordance with the relevant safety precautions. Key factors that help to assess the human health risk of chemical exposure include the duration, intensity (i. Wetland managers may be responsible for informing workers about the chemical hazards involved and implementing disinfection control measures. Where required, wetland managers should be able to readily provide workers with appropriate personal protective equipment and Material Safety Data Sheets (usually available on the internet) for each chemical or mixture of chemicals that may be in use. Chapter 4, Field manual of wildlife diseases: general field procedures and diseases of birds. Animal health authorities should be contacted to advise on appropriate measures remembering that the health and safety of the personnel involved in any disposal operation are paramount. Rapid and effectively planned carcase collection and disposal is essential to prevent spread of infectious disease and to reduce potential secondary poisoning in the case of toxic diseases. Presented below is a broad overview of the most commonly used methods for animal carcase collection and disposal, each has strengths and weaknesses which should be considered in the context of each specific situation. Collection of carcases Ideally carcases can be dealt with in situ to reduce chances of spread of infectious agents. However, in most circumstances where an outbreak has occurred and there are a number of carcases, they will need to be gathered to a central location for disposal. To help prevent potentially contaminated body fluids leaking during collection and transport to the central location, wherever possible (depending on size of dead animal), the carcases should be double bagged in plastic leak-proof bags (noting that claws, beaks etc. Wooden containers are difficult to decontaminate as fluids soak into wood so, wherever possible, plastic or metal bins/barrows etc. If carcases are being transported off-site to disposal facilities this must be done in leak-proof vehicles. Advice should be sought from animal health authorities regarding transportation of potentially infectious carcasses. Burial of carcases This is the often a preferred method of disposal as it is relatively easy to organise, quick, inexpensive, has potentially fewer immediate environmental hazards and it is a convenient means of disposing of large numbers of carcases. However, the suitability of this method needs to be considered carefully in or around wetlands as pits must not contaminate ground water nor be susceptible to inundation. Also care must be taken to avoid later exposure of carcases to people or other animals. Open pits were historically used for this purpose but potential problems include exposure to scavengers and the threat to groundwater quality. If carcases do not decompose sufficiently then contaminants may leach from the pit. Closed pits are now generally favoured with at least a metre of topsoil laid over carcases. This restricts the carcases rising in the pit due to gas entrapment, helps prevents access to scavengers, absorbs decomposition fluids and facilitates odour filtration. Potential scavengers can be further dissuaded by the addition of lime or fuel oil to the carcases, or use of thorny plants such as acacia spread across the pit. Factors to consider include: height of water table distance from watercourses or wells access to site facilities available equipment required safety to personnel acceptability to landowner protection from public view distance from residences/roads surface slope cultural/historical considerations biosecurity considerations. Incineration (burning) of carcases Incineration of carcases is advantageous due to the generally pathogen-free solid waste by- product. However, factors to consider prior to burning carcases include: location of site prevailing wind direction access to site type of animal carcase involved fuel availability number of carcases to burn environmental considerations. Common methods of incineration include open air burning, fixed facility incineration and air curtain incineration. To achieve the high temperatures required to completely consume carcases in open air burning additional combustible materials (e. Carcases can be either put on a platform above a fire at ground level or within a pit.

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