By P. Marus. Gordon-Conwell Theological Seminary.

However buy generic atarax 25 mg, treatment gaps national target was set: 800 000 smokers to have stopped at the are substantial in all countries order atarax in united states online, in part four-week follow-up stage by March 2006 purchase atarax with amex. It is planned that an because of the cost and complexity of electronic appointments system will be available to smokers to multiple drug use 25mg atarax with amex. One strategy that has been proposed Results for the period April 2004–March 2005 show that around to reduce these barriers is a fixed dose 300 000 smokers had successfully stopped at the four-week fol- combination pill (now commonly known low-up stage compared with about 205 000 the year before (an as a polypill). Initial findings also show that equity of access apparently works in addition to the oth- to treatment is good, although success rates are lower among ers, net benefits are anticipated to be disadvantaged groups. As well as improving clinical outcomes, they simplify distribution of multiple medications, which can be an important advantage in a resource-limited health-care setting. The major challenge remains one of implementation – new strategies are required for the many millions of under-treated individuals with established cardiovascular disease in low and middle income countries. For people with cardiovascular disease in low and middle income countries, access to preventive care is usually dependent upon their ability to pay, and hence it is this large, underserved group that stands to gain most from a polypill (32, 33). Yet in many places, effec- tive interventions for chronic diseases are poorly delivered or are not available at all. In some settings, lack of human, physical and financial resources are the major constraining factors. In other settings, resources are available but are used in a fragmented In a rural South African setting, a nurse-led chronic and inefficient manner. Factors to take into account disease management programme for high blood include the following: pressure, diabetes, asthma, and epilepsy was » evidence-based decision support tools can improve established as part of primary health care for a the delivery of effective care for chronic diseases; population of around 200 000 people. The pro- » effective clinical information systems, including gramme included the introduction of: clinic-held patient registries, are an essential tool for provi- treatment cards and registries; diagnostic and ing the continuity of care necessary for chronic management protocols; self-management sup- diseases; port services; and regular, planned follow-up with a clinic nurse. Nurses were able to improve disease control among most of the patients: 68% of patients with high blood pressure, 82% of those with diabetes,109 and 84% of those with asthma (34). Five greater efficiency from their health systems health-care facilities, each with a multidisciplinary team of by combining disease management for all staff, were involved in the decision-making and planning of chronic conditions. They enable the » reallocation of financial and human resources to facilitate organization of patient information, tracking implementation of these services. Multidisciplinary health-care teams, centred on primary The Secretariat of Health of Mexico health care, are an effective means in all settings of achieving this has launched a “crusade for the goal and of improving health-care outcomes (37 ). It is possible, however, to provide some the implementation of a structured of the core skills from these disciplines in other ways (by training diabetes education programme. It may be possible to provide core trained to adopt a quality improve- aspects of effective health care that in more resourced settings ment methodology. Among the inno- would be provided by health professionals from several different vations in primary health centres disciplines. The while among those receiving usual production of an evidence-based guideline is a resource-intensive care the proportion only increased and time consuming process. Documented foot lines are available for many chronic diseases (see, for example, care education increased to 76% of http://www. For example, simply providing information about the guideline is likely to have little impact, but linking the guideline to workshops or outreach training sessions and providing prompts within medical records are much more likely to change practice (41). Inter- A chronic disease self-management programme was developed in Shanghai from 1999 to 2001. The ventions that aim to improve the ability of patients and their programme was conducted by trained volunteer lay carers to manage conditions can be highly effective and leaders and included exercise, the use of cognitive are an essential component of chronic disease care (46). In some conditions, communities and six districts of Shanghai, and is being notably after myocardial infarction, rehabilitation reduces replicated in other cities (43). Multidisciplinary and intensive rehabilitation programmes, common in high income countries, are typically not feasible in low and middle income countries. This included mobil- » Multidisciplinary rehabilitation services in patients with chronic ity training and training to perform normal low back pain can reduce pain and improve function (48). Quality of life improved for » Cardiac rehabilitation (following myocardial infarction), with a some 95% of participants (44). In many from targeted communities (villages and low and middle income countries, this rehabilitation approach is not slum areas) were taught to identify and feasible owing to shortages of health workers and other resource train people with disabilities. Review of effective interventions In these situations, community-based rehabilitation is a viable alter- native, using and building on the community’s resources as well as those offered at district, provincial and central levels. Community-based rehabilitation is implemented through the combined efforts of people with disabilities, their families, organizations and communities, as well as the relevant governmental and nongovernmental health, education, vocational, social and other services. Such efforts are being made in more than 90 (mostly low and middle income) countries. There have been As an overall approach, some important successes that might be applied nationally. For example, the Pain it has not been rigorously and Palliative Care Society in Kerala has developed a network of 33 palliative care evaluated but site-spe- clinics providing free care to those who need it, with an emphasis on home care. Palliative care ranges from which five countries – Botswana, Ethiopia, Uganda, United personal care and assistance in daily living to Republic of Tanzania and Zimbabwe – and the World counselling and pain management. The current evidence provides little guid- local nongovernmental organizations, particularly Hospice ance on whether one approach is superior to Africa Uganda, the Ministry of Health has included pain another and suggests that further studies would relief and palliative care in the home care package, based be useful (52–54). Services include essential drugs for pain and other symp- tom relief, food and family support. I was also having trou- ble remembering things and had to urinate a lot,” she recalls. After that, Zahida ignored her symptoms for eight long years before seeking medical care again, this time in Islamabad, 70 km from her home town. A second blood test finally established the nature of the problem and she started feeling much better almost immedi- ately after taking her first shot of insulin. One of her legs was amputated below the knee, as a result of an ulcer on her foot going untreated. Zahida holds her local hospital responsible for not having detected raised blood glucose in the first place, but admits that she should have reported the ulcer on her foot to her doctor much sooner. Now 65 years old, she is slowly recovering at home from the physical and emotional effects of surgery with the help of her son and daughter- in-law. Many of the complications of diabetes, such as leg 115 amputation, can be prevented with good health care. Chronic diseases are already the major cause of death in almost all countries, and the threat to people’s lives, their health and the economic development of their countries is growing fast. Yet, as this part of the report has shown, the knowledge exists to deal with this threat and to save millions of lives. Effective and cost-effective interventions, and the knowledge to implement them, have been shown to work in many countries. If existing interventions are used together as part of a comprehensive, integrated approach, the global goal for preventing chronic diseases can be achieved. The only question is how governments, the private sector and civil society can work together to put such approaches into practice. If they do so in the ways outlined in the next part of the report, the global goal for chronic disease prevention and control will be achieved and millions of lives will be saved. Reduction in the incidence of noncommunicable disease interventions: lessons from type 2 diabetes with lifestyle intervention or metformin. Changes in sodium intake and blood pressure in a mellitus by changes in lifestyle among subjects with impaired community-based intervention project in China. School-based health education quickly does reduction in serum cholesterol concentration lower programs can be maintained over time: results from the risk of ischaemic heart disease? Vartiainen E, Jousilahti P, Alfthan G, Sundvall J, Pietinen P, London, Food Standards Agency, Dairy Council, Health Puska P. Cardiovascular risk factor changes in Finland, 1972– Education Trust, 2004 (http://www. International workplace health promotion program conducted in Japan for Journal of Tuberculosis and Lung Disease, 2000, 4:1002–1008. Paper prepared for the Transportation Research screening for noncommunicable disease: World Health Board and the Institute of Medicine Committee on Physical Organization Consultation Group Report on methodology of Activity, Health, Transportation, and Land Use. The long-term impact of Johnson & Johnson’s Health los Andes, Corporation de Universidades Centro de Bogota, & Wellness Program on employee health risks. Journal of Occupational and Environmental and evaluation of the Agita Sao Paolo Program using the Medicine, 2002, 44:21–29. Implementing clinical for cervical cancer in low- and middle-income developing guidelines: current evidence and future implications.

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Effect of dietary cis and trans fatty acids on serum lipoprotein[a] levels in humans effective 10mg atarax. The metabolizable energy of diets differing in dietary fat and fiber measured in humans order atarax with amex. Diet composition purchase atarax 25mg, energy intake discount atarax 25 mg overnight delivery, and exercise in relation to body fat in men and women. Prevalence and determinants of glucose intolerance in a Dutch Caucasian population. Comparison of diets supplemented with fish oil or olive oil on plasma lipoproteins in insulin- dependent diabetics. Interactions between dietary fat, fish, and fish oils and their effects on platelet function in men at risk of cardiovascular disease. Fish consumption and cardiovascular disease in the Physicians’ Health Study: A prospective study. Changes in children’s total fat intakes and their food group sources of fat, 1989–91 versus 1994–95: Implications for diet quality. The gastrointestinal handling and metabolism of [1-13C]palmitic acid in healthy women. Decreased serum total choles- terol concentration is associated with high intake of soy products in Japanese men and women. Low-fat diets do not lower plasma choles- terol levels in healthy men compared to high-fat diets with similar fatty acid composition at constant caloric intake. The effect of dietary docosahexaenoic acid on plasma lipoproteins and tissue fatty acid com- position in humans. The effect of dietary docosahexaenoic acid on platelet function, platelet fatty acid composi- tion, and blood coagulation in humans. Problems with the report of the Expert Panel on blood cholesterol levels in children and adolescents. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Nutritional quality of a high carbohydrate diet as consumed by children: The Bogalusa Heart Study. Niinikoski H, Viikari J, Rönnemaa T, Lapinleimu H, Jokinen E, Salo P, Seppänen R, Leino A, Tuominen J, Välimäki I, Simell O. Prospective randomized trial of low-saturated-fat, low-cholesterol diet during the first 3 years of life. Niinikoski H, Lapinleimu H, Viikari J, Rönnemaa T, Jokinen E, Seppänen R, Terho P, Tuominen J, Välimäki I, Simell O. Growth until 3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and choles- terol. Niinikoski H, Viikari J, Rönnemaa T, Helenius H, Jokinen E, Lapinleimu H, Routi T, Lagström H, Seppänen R, Välimäki I, Simell O. Men who consume vegetable oils rich in monounsaturated fat: Their patterns and risk of prostate cancer (New Zealand). Energy intake and physical activity in relation to indexes of body fat: The National Heart, Lung, and Blood Institute Growth and Health Study. Effects of inherent respon- siveness to diet and day-to-day diet variation on plasma lipoprotein concentra- tions. 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Circulating levels of endothelial function are modulated by dietary monounsaturated fat. A Mediterranean and a high-carbohydrate diet improves glucose metabolism in healthy young persons. Impact of adopting lower-fat food choices on nutrient intake of American children. Role of life-style and dietary habits in risk of cancer among Seventh-Day Adventists. Intake of fatty acids and risk of coronary heart disease in a cohort of Finnish men. Dietary manipulation and energy compensation: Does the intermittent use of low-fat items in the diet reduce total energy intake in free-feeding lean men? Effect of dietary manipulation on substrate flux and energy balance in obese women taking the appetite suppressant dexfenfluramine. Dietary supplementation of omega-3 polyunsaturated fatty acids improves insulin sensitivity in non-insulin-dependent diabetes. Effects of physical and chemical characteristics of food on specific and general satiety. Effects of degree of obesity, food deprivation, and palatability on eating behavior of humans. Ad libitum intake of a high-carbohydrate or high-fat diet in young men: Effects on nutri- ent balances. Replacement of dietary fat by sucrose or starch: Effects on 14 d ad libitum energy intake, energy expenditure and body weight in formerly obese and never-obese subjects. Effect of a high sugar intake on some metabolic and regulatory indicators in young men. Insulin resistance, compensatory hyperinsulinemia, and coro- nary heart disease: Syndrome X revisited. Feasibility of using an oleate-rich diet to reduce the susceptibility of low-density lipoprotein to oxidative modification in humans. Effects of oleate-rich and linoleate-rich diets on the susceptibility of low density lipoprotein to oxidative modification in mildly hypercholesterolemic subjects. Effect of diets high in ω-3 and ω-6 fatty acids on initiation and postinitiation stages of colon carcinogenesis. Effect on fasting blood insulin, glucose, and glucagon and on insulin and glucose response to a sucrose load. The pattern of urinary stone disease in Leeds and in the United Kingdom in relation to animal protein intake during the period 1960–1980. The effect of high animal protein intake on the risk of calcium stone-formation in the urinary tract. The effect of test meal monounsaturated fatty acid:saturated fatty acid ratio on postprandial lipid metabolism. Relationships between serum lipids, platelet membrane fatty acid composition and platelet aggregation in type 2 diabetes mellitus. Influence of macro- nutrients on adiposity development: A follow up study of nutrition and growth from 10 months to 8 years of age. The specificity of satiety: The influence of foods of different macronutrient content on the development of satiety. Satiety after preloads with different amounts of fat and carbohydrate: Implica- tions for obesity. A randomized controlled trial of prenatal nutri- tion supplementation in New York City. Dietary supplementation of very long- chain n-3 fatty acids decreases whole body lipid utilization in the rat. Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. Single and combined prothrombic factors in patients with idiopathic venous thromboembolism. Effect of high-fat and low-fat diets on voluntary energy intake and substrate oxidation: Studies in identical twins consuming diets matched for energy density, fiber, and palatability.

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Consequently an effective vaccination campaign will confer benefits even to the unvaccinated proportion of the population (often referred to as ‘herd immunity’) order atarax with visa. The effectiveness of a vaccine in a given population is a function of the efficacy of the vaccine (i order 25 mg atarax otc. The level of vaccination coverage required to achieve disease control benefits will vary between host and pathogen populations 10mg atarax amex. Sustained effort will be required in order to maintain the benefits of vaccination in the face of sources of re-infection (e 25mg atarax with amex. Ongoing surveillance is, therefore, an important tool for monitoring the progress of vaccination programmes. Not all vaccines deliver life-long immunity and in some cases periodic re- administration may be required to deliver disease control benefits. Vaccination and disease surveillance Vaccination programmes may interfere with disease surveillance. For example, clinical surveillance may be more difficult in populations with a mixture of vaccinated and unvaccinated animals, as the disease may be unevenly distributed. Many serological tests cannot distinguish between antibodies that have been derived from vaccination or from natural infection, although some differential diagnostic tests do exist or may be developed. Interpretation of serology results can be greatly assisted by marking vaccinated animals, so that it is at least known whether samples have been taken from vaccinated or non-vaccinated animals. This may also be important to avoid the adverse welfare and financial implications of over-dosing individuals. Vaccination storage and application Vaccines should be stored at the correct refrigeration temperatures at all times and must be used before expiry dates. Selecting a vaccination programme When selecting a vaccination programme, the following should be considered: The programme should have a clear purpose and objective Once the target animal population and area have been defined, vaccination should be carried out as comprehensively as possible Separate vaccination personnel should be used for herds and flocks thought to have infection to minimise the spread of the disease between them Individual herds and flocks should be gathered separately to minimise the spread of disease Vaccinated animals should be permanently marked for future identification Vaccination programmes should be accompanied by other measures such as disease surveillance, livestock movement controls and quarantine (where possible and appropriate) Vaccination programmes should be accompanied by public awareness campaigns Examples of vaccination programmes: 1. Blanket vaccination is the comprehensive vaccination of ‘all’ susceptible animals over a large area. This may be favoured when the disease has become well established, when there are many sources of infection, or when other disease control measures are impractical and/or ineffective. Areas with known and suspected infection and areas thought to be at high risk of disease should be covered. Ring vaccination is the rapid creation of a belt of vaccinated animals around an infected area. This can be implemented to contain a fast spreading disease outbreak, in situations where the effectiveness of other methods is unlikely to succeed, or in areas which are too inaccessible for blanket vaccination or other disease control measures. Epidemiological factors and resource availability should be assessed to determine the width of the vaccination zone. Specific considerations for vaccination of wildlife Vaccination of domestic livestock has been widely used and may often present a practical disease control option where an effective vaccine exists. Vaccination of wildlife is more challenging owing to many technological and logistical barriers including difficulties in delivering it to a sufficiently large proportion of the target population. Also, only few vaccines have been tested sufficiently to demonstrate their safety and efficacy and achieve a licence for their use in wild hosts. Even domestic animal vaccines against the same pathogen, may need to undergo significant testing to determine their safety and efficacy in wild hosts. The aim of any wildlife vaccination programme needs to be clear from the outset, for example, does the vaccination programme aim to reduce mortality, reduce suffering, reduce the risk of spread to livestock or humans, or to ensure the viability of the population? There may be risks associated with the vaccine itself, either in target or non-target populations. Live vaccines have the greatest potential for problems following release into the environment. Also, the ecological consequences of vaccination should be considered, including the possibility of altering demographic processes (e. Delivery of the vaccine to the target population may be logistically difficult or prohibitively expensive. Methods of vaccine delivery include the injection of captured animals and the deployment of palatable baits containing vaccine. Capture and injection options are likely to be relatively expensive and could have adverse welfare implications. Deployment of edible baits is often a more attractive option, but the development of a suitable bait which is compatible with the vaccine and sufficiently stable in the environment can be technically challenging. Some well-resourced wildlife vaccination programmes such as rabies vaccination for red foxes Vulpes vulpes in Europe have proved successful. Other successful projects have involved vaccination of endangered wild populations against domestic animal diseases for which vaccines already exist, where populations were relatively restricted in range and well studied, and the aims of the project have been clear. Vaccination of wildlife can be successful and may seem like an appealing option, however, other management techniques, particularly where naturally acquired immunity is developed, may be just as effective and in many ways preferable. Buffalo treatment campaign in Iraq Breeding marsh buffalo Bubalus bubalis is important in different parts of Iraq, particularly in its southern regions and wetlands such as the Central marsh due to the abundance of appropriate food, water and pasture land. Unfortunately, many by-products of modern technology and poor water management policies have damaged the natural environment of these areas. This in turn necessitates the existence of veterinary centres to provide the proper treatment and vaccines needed for healthy buffalo populations. Due to an apparent lack of training and proper supplies, there is the potential for these centres to spread and worsen some diseases that afflict buffalo and cattle, such as septic blood haemorrhages and other diseases. These diseases lead to substantial losses in livestock, so consequently the authorities have instituted serious measures with the close support of Nature Iraq, an Iraqi environmental organisation, to contain these diseases through a campaign for fast and effective treatment of haemorrhagic blood septicaemia and other diseases. Main diseases that afflict buffalo: Haemorrhagic septicaemia Symptomatic anthrax The focus of this report is the prevention of haemorrhagic septicaemia. The following are the vaccines used in the prevention of this disease: Haemorrhagic Septicaemia Vaccine (H. Haemorrhagic septicaemia This is among the most common diseases infecting buffaloes throughout Iraq as well as in other African and Asian countries. After 13 years of two epidemiological studies in India, this disease was determined to be the more deadly than diseases such as cow plague, foot and mouth disease and symptomatic anthrax. It is caused by the bacterium Pasteurella multocida and it is pathogenic in cows and deadly for buffaloes. Infection Cows and buffaloes which carry the disease are considered the main source of the disease, which can exist inside the mouth of other nearby animals that can infect them directly or indirectly. The high rate of infection is closely tied to the animals’ wetland habitat and the close quarters the herds experience at night inside their enclosures. Clinical signs The infected buffaloes can be recognised by sluggishness, lack of movement, salivation, increased temperature, difficulty breathing, breathing through their mouth, nose excretions, and throat or neck lesions sometimes extending to the chest, as well as fluid in the throat and lungs. The vaccination should also vary according to local conditions in various countries but it is essential that the vaccination must begin early, as soon as the disease is detected. There are methods to help buffaloes survive the disease by making a slot in the trachea of the animals to give more time for the vaccine to work. It is possible to inject the animals intravenously whilst executing this minor surgical procedure at the same time by using anaesthetic. In this project, work continued for a period of forty-eight days during which time 18,331 buffalo and 1,229 cows were treated in several regions of Thi Qar province, as shown in the following table. Number of Number of Number of District & sub-district vaccinated buffaloes breeders vaccinated cows Suk Ash-Shuyook 6448 412 - Al-Taar 1488 62 - Al-Aslah 1479 51 846 Al-Cidaynoweya 617 28 - Al-Fuhood 2232 81 - Al-Chibayish 3783 252 60 Al-Hammar 1290 44 85 Karamatt Bani Saeyid 994 81 238 Results The following results were obtained from the vaccination campaign: Improved conditions and help in controlling haemorrhagic septicaemia in the visited villages; Increased health awareness of Iraqi buffalo breeders; Creation of a trusting relationship between the citizens and Nature Iraq; Motivated the veterinary centres in Thi-Qar to contribute to increasing veterinary awareness for the people; Stopped the disease’s migration from an infected area, and entrusted stewardship of the environment to the local people. Manual of the preparation of national animal disease emergency preparedness plans. Manual of diagnostic tests and vaccines for terrestrial animals – principles of veterinary vaccine development. Assessing the risks of intervention: immobilization, radio-collaring and vaccination of African wild dogs. For both wildlife and indigenous breeds of livestock, natural selection for genetic resistance to pathogens occurs over time, and, generally where the relationship between host and pathogen is well established, a balance is acquired. Selective breeding has traditionally been achieved by cross-breeding two individuals, each possessing a favourable trait, to obtain one offspring with both. This is normally a lengthy process requiring many breeding cycles to eliminate undesirable traits that may also be inherited. Genetic manipulation allows the desired genes (and therefore traits) to be spliced directly into organisms and removes the randomness of sexual genetic recombination making the breeding process more targeted and efficient. These techniques have the potential to provide powerful and sustainable solutions to global health problems because they are effective, specific and can reduce pesticide use, which in turn reduces resistance and environmental damage. Genetic manipulation of hosts and habitats Where disease resistance is known to have a genetic basis, traditional selective breeding can be used to generate resistant individuals and much research to date has focussed on breeding host individuals with immunity to a disease.

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It is an approach to healthcare that presents an opportunity to bring people together to work on big issues of common interest atarax 25mg discount. There are opportunities for industry to develop new business models based on the widespread use of digital technologies generic 25 mg atarax amex. Personalised medicine also goes hand-in-hand with the development of 2 The Council conclusions on personalised medicine for patients can be consulted on the web page: http://eur- lex cheap atarax 10mg otc. While the regulatory aspects of some of the new technologies are being addressed buy 25mg atarax with mastercard, there remains the issue of the cost of personalised medicine. Roberto Viola, Director-General for Communications Networks, Content and Technology, addressed the issue of data. For example, computing power needs to be increased, with the possibility of creating a European science cloud. The Directorate-General for Communications Networks, Content and Technology plays various roles in the personalised medicine initiative; considering activities in e-Health, Big data and High Performance Computing. The regulatory aspects are equally important: such as data flows, cybersecurity and data exchanges. Using breast cancer as an example, he said molecular analysis has shown that there is not one, but several types of the disease. Yet will these new treatments help a woman with cancer who also lives in a deprived area and may also be suffering from obesity and diabetes? Personalised medicine may be a way of closing the gap between clinical medicine and the other aspects of real life that affect human health. These differences can be captured in data, but patients must consent to provide this data. Another question is whether it will be possible to produce a better quality of care at a reduced cost. This will require a shift from a system that reacts to disease to one that seeks to prevent disease. Patient-reported outcome statistics will make it possible to establish which interventions are necessary and which are not. Anders Olauson, Honorary President of the European Patients’ Forum, ended the session with a call for patient empowerment. This entails giving patients access to information that will enable them to work with doctors in the management of their own healthcare. Personalised medicine puts the patient at the centre of healthcare decision-making. She illustrated this with an example of a woman whose aunt had a gene mutation which was predictive of cancer. After genetic counselling, the woman asked to be tested and discovered that she too was positive and had a risk of developing cancer. This points to a new model for care where the patient is engaged in researching aspects of his or her own health. Diagnosed with lymphoma in 2005, Peter Kapitein is a founder of the patient advocacy group Inspire2Live. Based in the Netherlands, Inspire2Live has about 34 members who are living with cancer. They meet with clinicians, scientists and business people to identify parts of the cancer healthcare system that could be improved. The group supports a fundraising event each year where cyclists bike up and down Alpe d’Huez in the French Alps six times in one day. They are: engage people with different perspectives; search for the root cause of a problem; think on a big scale, and remain independent. Rudi Westendorp of the Center for Healthy Aging, University of Copenhagen, spoke about the relevance of personalised medicine to ageing. Prof Westendorp is author of the book, Growing Older Without Feeling Old: on Vitality and Ageing. He said that elderly citizens are concerned about disease but also about the quality of their lives. Members of the cooperative can decide to share their data with doctors or participate in medical research. This is one initiative to bring healthcare companies together to help the end-user, Prof Westendorp said. Jan Geissler, Director of the European Patients’ Academy on Therapeutic Innovation, told the meeting that patients need to be involved early in the clinical development of new medicines. A cancer patient for 15 years, Mr Geissler has many advocacy roles including as a co-founder of a global network of leukaemia patients. He said patients should be involved in the design of clinical studies, not just the final stages of these trials. The European Medicines Agency has set an example by involving patients in some of their committees. These social values include what interventions are appropriate for patients at the end of their lives. Only patients and their carers know exactly how a disease impacts them personally and how specific treatments can affect their life quality. But in fact patients themselves may be more concerned about pain, anxiety and depression than mobility. Panel discussion In the discussion that followed, speakers said that patients have too long been viewed as subjects of research rather than active partners. György Németh of Gedeon Richter Plc captured the mood when he said that if patient engagement were a drug it would be the “blockbuster of the century. Peter Kapitein asked why, for instance, patients are not consulted about which diseases to investigate. Maired O’Driscoll of the Health Research Board in Ireland said there is a great demand for information about how the health and research systems work. Jan Geissler said the European Medicines Agency does a great job involving patients in some of its discussions. Furthermore, once a product is on the market, patients need to be involved in reporting outcomes from their treatments. Rudi Westendorp said that the benchmarks used by public authorities to reimburse medicines may need to be revisited to take more account of patient needs. The following additional points were made:  We don’t yet know how to optimise consultations between patients and their doctors. But still to be measured are the indirect costs to families;  Information obtained from patients about their treatments – patient- reported outcomes – is valuable. The healthcare community will need tools that can store this data, which includes clinical information as well as data on lifestyles. Furthermore, research into data collection, storage, harmonisation and security is needed, as well as strategies to make sense of this data. Similarly in personalised medicine, both hardware and software approaches can aid research and help optimise health systems. In parallel, solutions need to be found for managing access to data, and data ownership and privacy. This will require research into the ethical, legal and social dimensions and new innovative approaches. The protease and reverse transcriptase proteins include more than 300 different amino acids which are relevant to the design of new therapies. Taking this one step further, physicians have been able to extract samples of the virus from a patient’s blood and test these samples against all possible drugs. The procedure has been computerised thanks to the work of EuResist, an international research project that received funding from the European Commission under the Sixth Framework Programme. EuResist assembled data from 10 European centers covering the medical records of 65,000 patients over a period of 20 years. Cancer is also moving from a fatal to a chronic disease, at least for some types of cancer. Genomic information is important but so is data on a patient’s diet and lifestyle and on the environment.

It highlights the need for education and training of all categories of staff — from referring physicians to technicians buy atarax on line amex, nuclear medicine specialists order atarax 25 mg mastercard, medical physicists order atarax 10mg mastercard, engineers and others involved cheap 25 mg atarax with mastercard. The overriding principle is that any investigation should offer the maximum benefit to the patient and limit the radiation exposure. These principles have been widely accepted and have been introduced into the legal framework in most countries around the world. In spite of this, there have been many reports of radiological examinations that were not justified [7, 8]. It is evident that the implementation of the justification principle is not satisfactory, neither in nuclear medicine nor in diagnostic radiology, although some very helpful work has been done, for example, by the Royal College of Radiologists in the United Kingdom [9] and by the European Commission [10]. From the radiation protection point of view, it is a real challenge to use such guidelines in daily clinical work. Once clinically justified, each diagnostic examination should be conducted so that the dose to the patient is the lowest necessary to achieve the clinical aim. The optimization process necessarily requires a balance between administered activity, patient radiation dose [11] and image quality. In nuclear medicine, there is an urgent need to define objective criteria of what should be seen in an acceptable image and for systematic observer performance studies of the same type as has been carried out in diagnostic radiology for a decade [12]. Today, the quality of nuclear medicine images is most often assessed through subjective judgements. Diagnostic reference activities should be implemented as a first step to eliminate inappropriate imaging conditions. However, radiopharmaceuticals are occasionally administered to pregnant patients either due to clinical necessity or by mistake. In the first case, the diagnostic test is of high importance for maintaining the health of the mother. In the second case, an embryo or foetus may be irradiated unintentionally because the mother is not aware of her pregnancy, does not wish to admit it, or — against international recommendations [6] — has not been asked whether she is pregnant. Female patients of fertile age should routinely be interviewed and tested for pregnancy before an investigation [13]. As routine pregnancy tests may give misleading results, additional investigations by means of ultrasound could be performed to exclude pregnancy at the time of investigation. It is also necessary to have strict procedures to verify that the patient is not breastfeeding. In Europe, the Medical Exposure Directive 97/43 [17] introduces special attention to the protection of the unborn and breastfed child exposed in medicine. It is necessary to take radiation protection aspects into account already at the design stage of the facility and to install shielding [18]. For the staff, one important source of radiation exposure is handling of radioactive material during its compounding and administration to patients, the need to position the patients for imaging, attending patients who have had radioactive compounds administered to them, and the operation of equipment used. In a study of the doses to fingers and hands, it was shown [20] that training and education in good practice are more relevant parameters for dose reduction than the worker’s experience level. For the lens of the eyes, recent evaluations [21] show threshold doses for induction of cataract, which are ten times lower than deduced from earlier studies. Thus, the yearly equivalent dose limit for the lens of the eye at occupational exposure has been reduced from 150 to 20 mSv (averaged over 5 years and not more than 50 mSv in any one year) [21]. Personnel involved in nuclear medicine must have good knowledge of radiation protection. With good routines, yearly effective doses to staff members in a nuclear medicine department can be limited to a few millisieverts. Ward nursing staff may also be exposed from patients who need extensive nursing care and this category of staff can also reach effective doses of a few millisieverts per year. For this group, it is especially essential to be provided with information and education in radiation protection. For all groups of staff, it is essential to establish routines which guarantee that doses to pregnant women are such that the dose to an embryo/foetus is kept under 1 mSv [11]. Designing the layout of a facility and appropriate installation of shields are mandatory. The contact time between nurse and patient, and exposed radiation dose of nurses were recorded and assessed. So far, this has been widely conducted through the automatic exposure control mechanism. Good layout of a facility and appropriate installation of shields reduce the radiation dose to staff members. The paper provides some background on how to reduce doses in the field while keeping quality high. As referred to in several peer reviewed papers that were read to get the background on this subject, I found an interesting fact. To incorporate this recommendation into practice, several quality control steps have to be added to the programme. The first step would be to have a physician review the images when the stress portion is complete along with the gated images. A large single-centred study with 16 854 patients and an experienced reader demonstrated this very point [2]. If the camera has a software feature that allows the transmission scan to be moved around in the cardiac programme, effective radiation dose to the patient can be further reduced by only performing one transmission scan, and processing both the stress and rest portions with this same transmission scan. According to DePuey’s article on patient centred imaging, “effective radiation dose using a rest-stress protocol with 10. Again, wherever possible, protocols should be incorporated that allow you to do stress tests only to give the patient the lowest dose achievable. To provide the highest quality study, a two day protocol will need to be incorporated for patients who are over 90 kg. Patients who are above this weight tend to have a scan with an attenuation artefact and this can lead to non-diagnostic studies with low dose imaging. Prone is again an option to use whenever there may be questions about artefacts in the inferior wall. Peer reviewed literature supports the fact that this patient population has a tendency to have diaphragmatic attenuation artefacts. The most important point to take from DePuey’s article is that the effective dose using 99 a stress-only protocol with 25 mCi is estimated at 6. If a new camera based solid state detector is available, which generally has higher sensitivity and employs the newer reconstruction algorithms, it may be possible to adjust the dose as low as 50% as compared to gamma cameras that use sodium iodide crystals. These cameras were first introduced in an upright position, which eliminated some of the attenuation artefacts that showed up during supine imaging. Owing to the short imaging time, a half dose full time imaging or a full dose half time imaging can be employed, depending on the age and condition of the patient. This alone can greatly reduce the dose to the patient population, especially in younger patients where the radiation is more pertinent to their lifetime accumulation to cancer risk. Caesium iodide or cadmium zinc telluride have proven to be very expensive but improve sensitivity and energy resolution. Generally, cameras that use 3-D mode need less of a radioisotope than cameras that have to operate in 2-D mode. Operating in 3-D mode makes it possible to decrease the dose to the patient to as much as 1. If there is a cyclotron in the hospital, and ammonia can be used, an even lower dose could be given as in 3-D mode only about 10 mCi is needed, which puts the effective dose at roughly 1. There are studies that report that, with list-mode and the right use of processing software, one dynamic study can be acquired and the software can be used to create the gated and perfusion images. With this type of hardware and software, the effective radiation dose to the patient can again be reduced just by eliminating extra acquisition scans. Older cameras that do not have this type of hardware and software would require that four doses be injected to achieve both the dynamic study for coronary flow and another for the gated imaging. Rubidium can be produced in a generator every four, five or six weeks depending on the number of patients. Technically, the technologist can also influence the exposure to a patient by adjusting several of the components of the cardiac study. First of all, if the energy window is widened, there can be an impact on the counts acquired in a study. As a technologist, it is necessary to note the downside of widening the window, as it will also increase the scatter, which reduces image contrast. If the camera has iterative scatter correction, there will be less of a problem with this reduction in image contrast. Generally, step-and-shoot reconstruction algorithms are set up to input data that are collected at distinct angles.

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Geographic distribution The disease has been reported in North and South America buy atarax 10mg free shipping, Asia buy atarax no prescription, the Pacific and Europe cheap atarax 25mg amex. How is the disease Horizontal transmission: direct contact generic atarax 25 mg overnight delivery, cannibalism, through the water. Movement of ranaviruses into an area will most probably happen by movement of infected amphibians, fish or reptiles or via equipment and other inanimate objects that have been contaminated with ranaviruses. The viruses are highly infectious and capable of surviving for extended periods of time in the environment, even in dried material. Diseased larval amphibians often have swollen bodies and signs of internal and cutaneous haemorrhage. Affected adult amphibians may have reddening of the skin, skin ulceration, bloody mucus in the mouth and might pass blood from the rectum; often there is systemic internal haemorrhaging (which also may be seen in affected fish and reptiles). These signs are all typical of the disease syndrome ‘red leg’: ranaviruses are not the only possible cause of ‘red leg’ in amphibians and other differential diagnoses should be borne in mind. Seasonal variations in disease outbreaks have been reported, with both their prevalence and severity being greater during the warmer months, therefore temperature is considered a likely factor influencing disease outbreaks. Dead animals should be submitted to a suitable diagnostic laboratory for post mortem examination. Surveillance of live animals should be carried out if possible and sick animals submitted for testing. Diagnosis Liver and/or kidney samples from dead animals should be sent to an appropriate laboratory for diagnostic testing. Toe or tail clips from live animals might also be used for diagnosis, but the reliability of these has not been validated. Before collecting or sending any samples from animals with a suspected disease, the proper authorities should be contacted. Samples should only be sent under secure conditions and to authorised laboratories to prevent the spread of the disease. Although ranaviruses are not known to be zoonotic, routine hygiene precautions are recommended when handling animals. Also, suitable precautions must be taken to avoid cross contamination of samples or cross-infection of animals. Ideally any site containing a reasonable population of amphibians should be monitored for sick and dead animals as a matter of course. If sick or dead animals are found, they should be tested for ranavirus infection so that the site’s ranavirus status can be determined. People coming into contact with water, amphibians, reptiles or fish should ensure where possible that their equipment and footwear/clothing has been cleaned and fully dried before use if it has previously been used at another site. To properly clean footwear and equipment: first use a brush to clean off organic material e. Ideally, different sets of footwear should be used at the site than are used by staff at home. Biosecurity measures should be increased to reduce the chance of spread if disease is confirmed. Livestock It is important to reduce the chance that livestock moving between sites (especially those travelling from known infected sites) will carry infected material on their feet or coats. Foot baths can be used and animals should be left in a dry area after the bath for their feet to fully dry before transport. Wildlife Do not allow the introduction of amphibians, reptiles or fish without thorough screening and quarantine for ranavirus. This screening may still not pick up all subclinically infected individuals but will reduce the risk of actively infected animals being introduced to the site. Humans must ensure that all biosecurity measures described above are Humans followed to prevent introduction of the infectious agent into previously uninfected areas. The disease has been shown to cause significant population declines of common frog Rana temporaria in the United Kingdom, apparently following virus introduction from North America. Ranavirus infection might be implicated in declines elsewhere, but data are lacking. There are potential economic losses due to potential risk of disease spread to fish. An insect-borne viral disease that primarily affects animals but can also affect humans. The virus is mostly transmitted by the bite of infected mosquitoes, mainly of the Aedes species, which acquire the virus when feeding on infected animals. The disease can cause abortions and high mortality in young animals throughout its geographic range. In humans it causes a severe influenza-like illness, with occasionally more serious haemorrhagic complications and death. Species affected Many species of terrestrial mammal, particularly sheep, cattle and wild ruminants, although most indigenous livestock species in Africa are highly resistant to the disease. Geographic distribution Endemic in tropical regions of eastern and southern Africa, with occasional outbreaks in other parts of Africa. Major epidemics occur at irregular intervals of 5-35 years: in Africa, outbreaks typically occur in savannah grasslands every 5-15 years, and in semi-arid regions every 25-35 years. Epidemics are associated with the hatching of mosquitoes during years of heavy rainfall and flooding. Aedes, Anopheles, Culex, Eretmapodites and Mansonia species) and other biting insects. In mammalian species the virus can also be transmitted to the foetus of an infected female. How does the disease The main amplifying hosts are sheep and cattle and once livestock are spread between groups of infected, many species of mosquitoes (e. Eretmapodites and Mansonia species) and biting insects can then spread the disease to other animals and humans. Transmission can also occur through direct contact, which may become relatively more important as an outbreak progresses. The disease may be spread by ingesting the unpasteurised or uncooked milk of infected animals. There is a higher risk of an outbreak in irrigated areas or if there is surface flooding in savannah or semi-arid areas followed by prolonged rains, if the mosquito populations are high, and if there is concurrent illness. Humans may suffer from influenza-like symptoms which can include fever, headache, muscular pain, weakness, nausea, sensitivity to light, loss of appetite and vomiting. Complications can lead to ocular disease (with loss of vision), meningoencephalitis, hepatitis, haemorrhagic fever and occasionally death. Recommended action if Contact and seek assistance from animal and human health professionals suspected immediately if there is any illness in livestock and/or people. For dead animals, whole blood, liver, lymph nodes and spleen are preferable tissues for detecting the virus. Construct artificial homes or manage for mosquito predators such as bird, bat and fish species. Reduce mosquito breeding habitat: Reduce the number of isolated, stagnant, shallow (2-3 inches deep) areas. Install fences to keep livestock from entering the wetland to reduce nutrient loading and sedimentation problems. In ornamental/more managed ponds: Add a waterfall, or install an aerating pump, to keep water moving and reduce mosquito larvae. Keep the surface of the water clear of free-floating vegetation and debris during times of peak mosquito activity. Vector control (chemical) It may be necessary to use alternative mosquito control measures if the above measures are not possible or ineffective: Use larvicides in standing water sources to target mosquitoes during their aquatic stage. This method is deemed least damaging to non- target wildlife and should be used before adulticides. However, during periods of flooding, the number and extent of breeding sites is usually too high for larvicidal measures to be feasible. The environmental impact of vector control measures should be evaluated and appropriate approvals should be granted before it is undertaken.

When using homeopathy discount 25mg atarax, you have a choice of two different dilutions referred to as "x " potencies or "c " potencies generic 10 mg atarax free shipping. I have found that the c potencies are excellent for home use purchase generic atarax on-line, as their effect seems more pronounced than the commercial preparations order 25 mg atarax free shipping; many homeopathic doctors also prefer the “c” potencies. Combining homeopathy with urine therapy was, for me, incredibly effective for a wide variety of serious disorders as well as for mild disorders such as headaches, colds, indigestion, etc. External Use Skin Applications Applying urine to the skin is an excellent treatment for every 200 imaginable type of skin disorder including all rashes, eczema, psoriasis, acne, etc. The urea in urine, as the research studies demonstrated, is also excellent for cosmetic use as an overall skin beautifier and moisturizer. Use either fresh or old urine for skin applications, although old urine has a higher ammonia content and has been found to be more effective in treating many stubborn skin disorders such as eczema or psoriasis. Discard the pad and saturate another clean pad with fresh urine and reapply, lightly patting and soaking the affected area. Continue reapplying in this manner for 5-10 minutes or as many times as desired - the more that the affected area is treated, the better. Secure a clean soaked pad to the affected area with a gauze or cotton ~vrap and leave secured for several hours for additional healing. These urine packs are also incredibly effective for any type of insect sting, bite or poison oak or ivy. Another method is to pour old or fresh urine into clean, plastic spray bottle and spray the rash, eczema, etc. Skin Massages Always augment your use of oral urine therapy with skin massages particuJariy on the face, neck and feet John Armstrong recommended this practice especially when fasting for an acute condition, and people who use it, swear by it. These massages have a tonifying, refreshing, relaxing effect and are said to allow for gradual absorption of urine nutrients through the skin. Pour either old or fresh urine into a wide, shallow container and dip your hands into the liquid. Shake off excess, then vigorously massage into a small area of skin anywhere on the body until hands and skin are dry. Rewet hands and begin massaging another area until dry; repeat this step until all skin areas have been well massaged. If your own urine is dark, turbid or abnormal looking, wait until you have used the urine internally over the course of two or three days, at which time the urine usually appears clear and can then be used for massages. Urine from a normal healthy person other than yourself may also be used for your external massage. If you are a heavy smoker, or are taking therapeutic or recreational drugs, do not use your own urine externally or internally (or use only extremely small amounts). For cosmetic use or moisturizing, pour a very small amount of nor mal fresh urine or urme which has been stored, for a day or two into your hand and massage lightly into the skin until dry; then pour additional urine into your hand, massage it into another area of the skin until dry and so on. Also, you can add a few drops of urine to a small amount of your moisturizing cream each time you apply the cream. As the research studies show, urea replenishes the water content of the skin because it binds hydrogen and attracts moisture to the skin in a way that no mineral oil or glycerin-based lotions or creams can. Old dead skin immediately flakes away, and your skin becomes wonderfully soft, rosy and with time, even wrinkles will disappear. Soak gauze bandages or cotton balls m fresh or old urine and place them over the affected areas. Cover the urine pack with light plastic (like Saran-wrap) and tie in place with gauze strips. Try to keep the pack on as long as possible, especially with more, severe conditions. Add additional urine to the pack with a medicine dropper every few hours to keep the pack wet. Bites And Stings Urine packs are tremendously useful and effective for relieving the discomfort of all insect bites and stings. My foot immediately swelled to almost double its size and was unbelievably painhil. I dragged myself into the house, applied a soaked urine pack and tied it in place. Within 15 minutes, the pain had disap-peared and the swelling had lessened considerably. I kept the pack on overnight, and when I removed it in the morning, the swelling and redness had completely disappeared. The pain and irritation of bee stings and mosquito bites is also wonderfully relieved by this method. Follow emergency first-aid instructions to inrise the wound and remove venom, if possible. Then apply fresh normal urine to the wound and secure a well-soaked urine pack over it. Growths And Tumors Armstrong reported in great length on the remarkable effects of urine compresses in reducing and eradicating a wide variety of internal and external tumors, cysts and abnormal growths. Compresses should be used in combination with internal urine therapy for treating any type of abnormal growth. In preparing a compress, use a thick pad of clean white folded cotton material (such as an old T-shirt). Warm the urine by pouring it into a glass container, then place the jar in a container of hot water. While lying down, place wet compress over the affected area and cover with a clean folded towel. Keep the compress applied for as long as possible, reapplying warm urine as needed to keep the compress wet. Urine compresses have also been reported to be effective for many internal disturbances and for arthritic and rheumatic pains. Wounds, Burns And Abrasions As so many research and clinical studies have shown, urea is a tremen-dously effective anti-bacterial agent and an excellent healing treatment for wounds and burns of all types. Saturate a thick gauze bandage or cotton pad with fresh urine, place it over the wound or bum and secure it with additional gauze; cover with plastic or soft towel to prevent leakage. Reapply fresh urine with clean medidne dropper directly onto the existing inside compress. Urine is also known to prevent scarring, so keep the urine pack applied as long or as often as possible until healing is complete. The pain is quickly relieved and the burn or wound heals rapidly without scarring. Eye And Nose Drops There are reports from people who have used urme drops for both eye and nose drops, for relief of eye itching or inflammation, or for nasal congestion. In both cases, make certain that you are using fresh, clear, normal urine only and that the acidity factor of the urine is normal (see previous section on Monitoring Your pH in this chapter). A compress of fresh normal urine is also excellent for external eye inflammations such as styles. As the research studies indicate, oral or injected urea has been shown to be extremely effective and safe in treating cases where excess fluid production is a problem (see pgs. Using urea in conjunction with natural urine therapy can be discussed with your doctor, once he or she has been made aware of the research findings relating to urea and urine therapy. Oral urine therapy also allows for slower application and absorption which can decrease any possible de-toxifying symptoms. Gradual introduction of urine therapy, or any medical therapy is always important, but even more so if you have a history of poor nutrition or chronic, serious illnesses which weaken the body and 205 promote poisons and toxins in the system. Introducing a new therapy too rapidly places a strain on an ah-eady weakened system and can cause a sudden release of toxins that may make you feel ill unnecessarily. As clinical studies have demonstrated, oral urine or urea can be fust as effective for non-emergency cases as injected urine. However, if your situation is extremely severe, urine injections can definitely be of benefit. As several of the dinical studies showed, urea, even in large doses, has been found to be harmless to the body, Researchers, (Urea - New Use of An Old Agent), reported that they safely administered urea daily to several patients for a period ranging from several day» to weeks, and in some cases, even several months, without any side effects, in doses ranging from 100 mg. Uric acid, usually thought to be a toxic waste product of the body, has been found by researchers to actually be a natural body defense against cancer and aging, allowing us to 206 live much longer than other mammals (Omni Magazine article, 1982). Most people think that uric add causes gout, but strictly speaking, it is not the uric add alone that causes the gout, but rather an overall, ongoing and chronic overaridity in the body which can be caused by many different factors including improper, overly-arid diet, kidney, liver and adrenal disorders, obesity, diabetes, chronic stress, undereating (anorexia), etc.

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