By J. Hogar. Rust College.

New methylene blue (10 to 30 ml) may be used gested the best time for repair of teat stulas was during for dye injection into the stula best medex 5mg. This allowed several weeks for tissue re- then allows differentiation of stulas (or webbed teats) pair without concern of endogenous milk pressure or that have their own accessory gland (no dye in milk) or exogenous milking pressure being felt on the incision order medex 1mg on line. It may still be preferable to perform closure during Treatment the dry period after the udder is completely slack and the Surgical repair of stulas is identical to repair of webbed cow still has 3 to 4 weeks before freshening order medex 1mg otc. When webbed teats are repaired in Fine 4-0 absorbable suture material (3-0 if performed calves effective 1mg medex, determining the presence of an accessory gland during the dry period) placed in continuous fashion is is impractical and unnecessary because complete clo- preferred for mucosal closure in a continuous Cushing s sure will ensure eventual pressure atrophy of the acces- pattern. Generally 3-0 poly- glands rather than to the gland of the major teat but are glactin 910 or other absorbable material such as Monocryl not detected until the onset of lactation may be man- is used for stroma in interrupted fashion, and inter- aged in two ways: rupted 2-0 or 3-0 nonabsorbable sutures such as poly- 1. This approach disre- stroma and skin in one layer with interrupted 2-0 or 3-0 gards the accessory gland and relies on pressure nonabsorbable sutures in a vertical mattress fashion. This technique is Sutures are placed closer together than in other areas of best performed during the dry period to allow 4 full skin closure in the hope of more uniform closure pres- weeks of healing before the next lactation. Although not successful in our hands, some sur- technique may also result in some unbalancing of geons have used tissue adhesives for stula closure and the udder as the accessory gland atrophies. The common If stulas are repaired during lactation, it may be wise to wall between the two glands is removed, and the use indwelling teat cannulas that are left open to prevent mucosa of each gland is sutured over the defect endogenous pressure on the incision until healing is again using 4-0 absorbable suture. This allows a complete; however, the use of these should be balanced communication to be established between the teat by legitimate concerns for introducing mammary patho- cistern of the major teat and the cistern of the gens. The advantages of this technique are pres- several days and can be replaced by silicone inserts. Both ervation of milk production from the accessory insert types are commercially available in the United gland (which may be almost as large as the major States. The inserts have been shown to improve surgical gland in some cattle) and cosmetic appearance of results in lactating cattle. The disadvantages are that greater tech- nical skills are required to establish communication Lacerations of the cisterns and to suture mucosa to preserve the communication. Etiology The technique for repair of stulas is well accepted Trauma from the patient s hind foot or medial dewclaw, and includes elliptical incision around the stula, de- trauma by a neighboring cow, or lacerations from barbed bridement of necrotic or brous tissue (in acquired stu- wire or other sharp objects may induce teat lacerations. Associated mucosal damage, avulsion, or detach- severe cicatricial brosis are very difcult because tissue ment may lead to focal or diffuse cisternal obstruction. C, Teat cannula protruding from mucosal defect following en bloc resection of elliptical skin piece and stula tract. The streak canal is often transected, but a portion of the streak canal and sphincter remains proximal to the laceration and sufces for sphincter tone, barring future injury. Depth of laceration and duration of time since injury are important determinants when surgical repair is considered. Full-thickness lacerations may be obvious because of milk leak but sometimes are plugged with brin and B blood clots that mask the extent of the lesion. In fact, the distal ap of tissue is so swollen as to suggest laceration above the sphincter. Fortunately close examination of the wound will often reveal functional streak canal and sphincter muscle above (dorsal) to the swollen ap. Diagnosis The clinical signs and careful cleansing of the wound to allow detailed evaluation of depth sufce for diagnosis. The cow may need to be restrained or sedated to allow cleansing and inspection of the wound. Treatment C Owners neglect many supercial teat lacerations but tend to call veterinarians when the lacerations enter the cistern or cause mechanical interference with milking. Similar to lacerations anywhere on the body, teat lacerations are best approached as soon after injury as possible. A, Milking appears to cause milk to the wound is essential, and gentle debridement with a leak from the teat cistern. In general, vertical lacera- ap conrms the presence of remaining streak canal tions heal better than horizontal or circumferential ones. C, Removal Flaps that transect the streak canal should be clipped off of the ap restores teat function. Bruce Hull, Professor of Large Animal Surgery at the sutured similarly to the repair of teat stulas described Ohio State University, the wound is made with a previously. All principles are identical to repair of a sur- manure-laden foot rather than a sterile scalpel. Careful debridement, aseptic techni- Treatment of brous or membranous obstructions at the que, carefully placed sutures, and absolute closure of base of the gland cistern is not likely to be successful. Use of indwelling cannulas follow- teat and gland cisterns has been successful rarely, but ing surgery will help decrease internal pressure on the most surgical interventions are unsuccessful. The cannula should be left open to drain con- of teat obstruction is as described in diffuse teat-cisternal tinually for several days. Temporary or permanent teat implants of- for 3 to 5 days, and the quarter is infused with antibiot- fer the best success rates for heifers and cows that have ics following repair. Success rates of 50% or more are likely for this type of teat obstruction when Blind Quarters and Membranous implants are used. Stenosis or atresia of the teat end is treated by slow Obstructions dilation of the streak canal when the canal can be seen Etiology or by sharp puncture of the apparent dimple at the teat Blind quarters appear to be laden with milk at freshen- end when a streak canal cannot be identied. Congenital or acquired lesions sharp 14-gauge needle is directed into the teat lumen at that impair milk ow from the gland cistern cause blind the apparent dimple that correlates with where the quarters. After needle puncture, genital, acquired before rst lactation, or acquired as a the stenosis can be opened further with a bistoury. Leaking Teats Degeneration of the gland cistern and connecting ducts is the most common lesion found in freshening Etiology and Signs heifers that have either small amounts or no milk from a Many cows leak milk just before normal milking times quarter that appears to be of normal size. The condition because of intramammary pressure; this is considered is thought to be caused by intramammary infection or normal or physiologic. Such infections can be and that which occurs at times other than milking or that initiated by aggressive nursing of incompletely weaned affects show potential is considered abnormal. At the time the blind quarter is identied, masti- Generally milk leaking is more common in previ- tis is usually not present in the affected quarter. The injury has disturbed normal sphincter tone or integrity of the teat end by brosis or Signs loss of tissue so that leaking occurs. Anticipated quantities of milk cannot usually be obtained from the affected quarter. The teat usually feels abby and Diagnosis meaty rather than turgid, as expected in normal milk ll- Only the history and physical inspection of the teat are ing. The teat may be probed to assess in cases in which congenital or acquired cisternal obstruc- the streak canal diameter but seldom is this necessary. Treatment Injecting about a drop of Lugol s iodine solution with a Diagnosis tuberculin syringe at four equidistant spots in the sphinc- Careful probing of the teat cistern and gland cistern with ter muscles has been reported to correct leaking in ap- a 3- or 4-in (7. This technique also allows assess- Skin Lesions ment of any teat-cistern obstruction and permits milk to be obtained for examination. If the diagnosis is still in Viral Causes question following probing of the quarter or if surgical Bovine Papillomavirus treatment is contemplated, ultrasound examination is Etiology. Salicylic acid (10%) and g spread primarily by milking machines and milkers tree latex applied every 5 days has also been shown to be hands that carry the virus, which then infects the skin in effective. Because of the current concerns about transmission Florid warts that appear as classical papillomas or bro- of prions among cattle, autogenous vaccines cannot be papillomas with epithelial projections may be more recommended. Warts at the teat end The use of common utensils during udder washing sometimes interfere with effective milkout and always and drying should be avoided; udders should be washed predispose to mastitis because of environmental con- and dried with individual paper towels before milking. Herds with endemic instances of this type of Herpes Mammillitis wart can be extremely frustrating because means to stop Etiology. If signs are not pathognomonic, excisional herds where the virus has persisted in recovered older biopsy is conrmatory. The exact means of spread is unknown because numbers of cattle are affected, freezing of the warts by rather deep inoculation of the virus into the teat wall is application of a steel rod chilled to liquid nitrogen required for experimental reproduction of the disease. Several authors suggest an insect mode of transmission, but this theory does not coincide with the peak seasonal (fall-winter) incidence. Types of early lesions vary but may include vesi- cles, edematous plaques, and serum crusts. Initially vesi- cles form on the skin of the teat and udder, and the skin appears edematous. Sizes of lesions range widely from a few millimeters to several inches in diameter and vary in number in infected cattle.

The same mechanism may underlie the loss of response to recall antigens buy medex 5mg lowest price, with accompanying vulnerability to other infectious agents generic medex 1mg mastercard. The reason for this inhibition of T-cell synthesis is unclear generic medex 5 mg with visa, but it may involve more than one mech- anism purchase 1 mg medex. Stimulation by superantigen bind- ing nonspecifically to the T-cell receptor may cause the massive overexpansion of T-cell subsets and may also cause deletion of these subsets if they are already primed for apoptosis (35). Chronic immune activation and apoptosis eventually lead to loss of cell-mediated immunity directed against ubiquitous opportunistic agents. The chronic inflammation causes bystander damage, leading to complications such as dementia and wasting. This is followed by reduced immune activation and partial restora- tion of immune function (37). With the recent advent of potent antiretroviral therapy, the ability of the immune sys- tem to recover spontaneously has been demonstrated, and the limits of this recovery have also been seen (38 40). Other strategies being tested involve modulation of the immune response, to reduce the excessive activation. As these and other therapeutic interventions are developed, they present great challenges in clinical trial design. They are therefore used primarily in testing vaccines, since the prevention of infec- tion can be measured, but the impact of a therapy on disease course cannot. Their use is further complicated by the fact that they are an intelligent, endangered species, whose use as a laboratory animal is tightly restricted and very expensive. The expense of caring for macaques restricts the size of experiments using this model. Once trials have grown beyond the pilot stage, in which interventions in small num- bers of subjects yield data that help to guide the planning of larger trials, sufficient numbers of participants must be enrolled so that the outcome can be reliably attributed to something other than chance. The choice of end points is critically important to make sure that meaningful results are eventually obtained. However, the slow rate of progression of the disease required very large trials with long-term follow-up before sufficient numbers of events could display a signifi- cant difference between arms in a protocol. At the same time, although inter- ventions that may result in change in viral load can be tested against that measure, it is quite conceivable that an intervention could confer significant immunologic benefit with little impact on viral load. Validation of appropriate surrogate markers for immune-based therapies is the next hurdle in the advancement of this field. The choice of the population in which to test interventions is also an important con- sideration in clinical trial design. Patients with advanced disease, who have failed potent antiretroviral therapy, are eager to find alternate therapies, and their outcome might be relatively quickly learned. Unfortunately, many of the interventions being tried are the least effective and most toxic in subjects with advanced disease. Populations with a more intact immune response are therefore currently favored for trials of immune-based therapies. At the same time, if surrogate markers are being relied on for end points, there must be something to measure in the population chosen. For example, if change in viral load is chosen, then either the subjects must not have their viral load suppressed below the level of detection to begin with, or must have a likelihood of sufficient numbers of participants to experience viral breakthrough to be able to measure benefit from the intervention. An alternate model being explored is to withdraw therapy at some time and measure the rate or the magnitude of viral load resurgence as an end point. The possi- ble risks to participants of this study design are being carefully examined. Consideration must be given not only to the risk to the individual participant but also to the benefit to the com- munity from which participants are recruited. In the United States, for instance, considera- tion must be given to including women and minorities in the participants in clinical trials and to not unnecessarily barring participation by pregnant women. The data gathered from such trials must be relevant to the population of that country and the prospect must exist for the therapy being tested to be available there if found to be effective. An exquisite tension exists between the dire need for therapies in developing nations and the barriers of cost that may be insur- mountable. However, the lack of therapeutic options outside the clinical trials mechanism makes this group especially vulnerable to exploitation, and careful ethical review of clinical trials planned for developing nations is extremely important. The quantitative nature of the primary immune response is a prognosticator of disease progression independent of the initial level of plasma viremia. Grossly defective nef gene sequences in a human immunodeficiency virus type-1-seropositive long-term nonprogressor. Multifactorial nature of human immunodeficiency virus disease: implications for therapy. Development of the anti-gp120 antibody response dur- ing seroconversion to human immunodeficiency virus type 1. Global burden of tuberculosis: estimated incidence, preva- lence, and mortality by country. Immune reconstitution in the first year of potent antiretroviral therapy and its relationship to virologic resonse. Many questions remain, however, concerning the extent and clinical significance of the immune recon- stitution that occurs in the setting of antiretroviral drug therapy. The second phase increase has been found to correlate with age in some (89), but not all, studies (71,86). The second-phase increase, which primarily consists of cells with a naive phenotype, is similar in tempo to what has been observed in cancer patients treated with chemotherapy (102). Phenotypically naive cells are not necessarily newly synthesized, as reversion of cells from a memory to a naive phenotype has been reported (103,104). In general, the restoration of these responses has occurred rapidly, within the first 3 months of therapy. However, the recovery of responses was asynchronous; Candida responses were restored within 12 weeks of therapy, whereas mumps responses only increased after 12 weeks of therapy. These findings support the hypothe- sis that reexposure to antigen is necessary to reconstitute functional immune responses. Similar studies in humans are ongoing, but there are no definitive results to date. Nev- ertheless, immune reconstitution is neither uniform nor complete in all treated indi- viduals. A small fraction of individuals are absolutely intolerant of the medications and therefore unable to take them. Many others suffer side effects but con- tinue to use them with substantial impairments in their quality of life (147). As many as two-thirds of treated individuals do not achieve or maintain complete virologic sup- pression (147). Transmission of resistant virus is increasing (148), which limits the medica- tions that individuals infected with resistant strains may receive. Treatment of human immunodeficiency virus infection with saquinavir, zidovudine, and zalcitabine. Treatment with indinavir, zidovudine, and lamivudine in adults with human immunodeficiency virus infection and prior antiretrovi- ral therapy. Treatment with amprenavir alone or ampre- navir with zidovudine and lamivudine in adults with human immunodeficiency virus infection. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. Regression of progressive multifocal leukoen- cephalopathy with highly active antiretroviral therapy [Letter]. Remission of progressive multifocal leukoencephalopathy after antiretroviral therapy. Remission of progressive multifocal leukoen- cephalopathy after antiretroviral therapy. In: Abstracts of the 37th Inter- science Conference on Antimicrobial Agents and Chemotherapy. Resolution of azole-resistant oropharyngeal candidiasis after initiation of potent combination antiretroviral therapy [Letter].

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Hedhli N purchase medex 1 mg otc, Pelat M cheap 1 mg medex otc, Depre C (2005) Protein turnover in cardiac cell growth and survival medex 1 mg on line. Vinciguerra M generic 5 mg medex otc, Musaro A, Rosenthal N (2010) Regulation of muscle atrophy in aging and disease. Marzetti E, Calvani R, Bernabei R, Leeuwenburgh C (2012) Apoptosis in skeletal myocytes: a potential target for interventions against sarcopenia and physical frailty a mini-review. Mech Ageing Dev 57(2):187 202, 0047-6374(91)90034-W [pii] Cardiovascular Disease and Aging 151 103. J Gerontol A Biol Sci Med Sci 63(1):12 20, 63/1/12 [pii] Cardiovascular Disease and Aging 159 234. Physiol Rev 73(2):413 467 The Impact of Aging on Ischemic Stroke Farida Sohrabji Contents 1 Introduction 161 2 Stroke and Aging 162 2. Hemorrhagic stroke is due to weakening of the vessel wall and eventual rupture and spillage of blood in the brain parenchyma. Ischemic stroke is more common and can run the gamut from mild symptoms to chronic disability and death. Few therapies are available for stroke patients outside of rehabilitative therapy. Thus, while stroke incidence is low among younger demographics, the prevalence of stroke in the sixth seventh decade of life (60 79) is 6. The increased risk for stroke with age coupled with a growing aging population will lead to an additional 3. Besides elevating the risk for stroke, age also adversely affects stroke outcomes [128]. Stroke outcomes can be assessed by several measures including survival, functional recovery, and length of hospitalization. Furthermore, hos- pitalization length was signicantly increased in older patients (>65 years) with stroke [225]. Observational studies in university hospital settings reported that age was a highly signicant predictor of poor functional outcome [1, 66, 139]. Moreover, a small study of centenarians also conrmed that strokes were much more severe in this population than in other age groups [207]. Morphologically, aging is associated with decreased salvage of penumbral tissue, and leptomeningeal collateral circula- tion is reduced in aging stroke patients, which associated with a poorer outcome [15 ]. Based on the evidence above, age is often referred to as a non-modiable risk fac- tor for stroke. In evaluating this statement, it should be recognized that the aging demographic is a highly variable one. Sex/gender differences, life style factors, and The Impact of Aging on Ischemic Stroke 163 ethnicity all impact stroke incidence. Thus while age is a contributing factor for many illness, the relatively lower incidence of stroke in the aging population suggest that other factors may also mod- ulate age to elevate the risk for this disease. Most ischemic strokes occur in the elderly and among this elderly demographic, women are more likely to get a stroke [217]. In addition to a higher incidence of ischemic stroke at older ages, females display more non-classical stroke symptoms and tend to have worse outcomes from stroke. Thus while stroke is the 4th leading cause of death overall, it is the 3rd leading cause of death in women, and the 5th leading cause of death in men [193]. In fact, the rates of stroke-related death have declined over the last 25 years for men but not women [232]. Furthermore, since women live longer than men, it is projected that stroke-related disability and insti- tutionalization is likely to affect women more than men [145]. Women account for 60 % of stroke-related deaths [169], even after normalization for age. The 5 y stroke recurrence is also disproportionately higher in females (20 %) as compared to males (10 %) in the 45 64 years age range [232]. A Canadian stroke registry study reported that 10 % of women stroke patients were discharged to long term care as compared to 5 % of men [133], despite the observation that stroke size tends not to be different in males and females [248]. In the Danish National Registry analysis, women were reported to have more severe strokes than men although they exhibited a survival advantage compared to men, especially at advanced ages [206 ]. The increased incidence of stroke among older women, especially when com- pared to the relative low risk among younger demographics has led to the hypothe- sis that the loss of ovarian hormones, principally estrogen, at menopause may be a contributory factor. However, analysis of hormone use and stroke incidence in post- menopausal women does not support this conclusion. An early case control study reported no increased risk for stroke in postmenopausal women who took hormone therapy, relative to those not taking hormones [216]. In a different multicenter case- controlled study, increased lifetime exposure to estrogen was associated with a lower risk of stroke, but interestingly, a lower age at menarche increased the odds of stroke [63]. Sohrabji groups showed an increased risk for stroke; however, subgroup analyses indicated that most of this risk was seen in the older age groups. In an observational analysis of postmenopausal women in the Nurse s Health Study, estrogen and estrogen + progestin use increased the risk of stroke irrespective of the age of the user or time since menopause [107]. The timing hypothesis postulates that hormone treatment is likely to be cardio- and stroke-protective only if taken during the perimenopause or early after menopause. The accumulated evidence of sex differences in the incidence, mortality and out- come for stroke prompted the recent American Heart Association/American Stroke Association guidelines for sex-specic recommendations for the female stroke patient [41]. Thus the aging woman may represent a specically vulnerable population for stroke. One report estimates that non-hypertensive individuals aged 55 65 are virtually all (90 %) likely to develop stage 1 hypertension and are at a 40 % risk of developing stage 2 hypertension [271], underscoring the close link between aging and hypertension. Systolic blood pressure rises gradually between 30 and 80 years of age, and systolic hypertension is very common after age 50 [219]. Hypertension is seen in 77 % of all stroke patients [169], and the Framingham study reported that hypertension was the factor most strongly associated with stroke in elderly males and females, increasing the odds ratio of stroke 1. This pattern is thought to reect a transition from age-related changes in peripheral vascular resistance to large artery stiffness [89]. Both aging and hypertension can impair endothelial, and therefore, microvessel function. A series of studies examining the effect of anti-hypertensive therapy in elderly patients showed that such interventions reduced all strokes 30 57 % compared to placebo, and reduced fatal strokes by 39 76 % (reviewed in [14]). Thus aggressive management of blood pressure in the elderly may dilute the impact of age on stroke. This may underlie the steady decline in stroke mortality and stroke-associated dis- ability among the elderly that has been reported between 1967 and 1985, although the incidence of stroke remains high in this group [24]. While control of risk factors including hypertension, hyperlipidemia, diabetes and cigarette smoking are neces- sary at all ages, they are most likely to be benecial in the elderly [25]. Sohrabji there appears to be no age threshold where treatment for hypertension is not likely to be benecial for stroke [16]. Elevated cho- lesterol and lower levels of high-density lipoproteins are associated with stroke in aging and lipid-lowering drugs reduce the incidence of myocardial infarction [6, 237]. While major trials have indicated that statins are well tolerated in the elderly, the association between hyperlipidemia and stroke is not strong in this group. However, this may also result from other protective actions of statins on the endothelium, including anti-oxidant, anti-inammatory effects and stabilization of plaques [179]. After age 65, blood lipid levels are less prominent risk factors for cardiovascular diseases and by age 75, blood lipids have little predictive value [29]. In fact, specic lipids may be associ- ated with longevity in the elderly population, for example sphingomyelin in women [103, 238]. Thus among the elderly the risk imposed by hypertension is likely more severe than hyperlipidemia. In current smokers this risk is elevated irrespective of the pack-years of smoking exposure [104]. Remarkably, prior to 75 years of age, hypertension and diabetes are much less important risk factors as compared to heavy (>2 drinks/day) alcohol consumption at midlife [129 ]. Altered glucose metabolism is not necessarily a component of aging, and may represent a sub population that is generally at higher risk for other adverse geriatric processes [131]. Some support for this idea comes from the fact that vascular disease increases before the elevation of glucose levels and more than 25 % of newly diagnosed diabetic patients already have cardiovascular disease [281 ]. The convergence of comorbid disease and sociocultural stressors during aging as risk factors for stroke ts well with the concept of an allostatic load [182].

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The organism enters the fairly common purchase medex 5 mg without a prescription, with or without treatment purchase 1 mg medex otc, and brain as well as the eyes and can cause mental the fresh choroidal inammation tends to arise deciency and epilepsy order 1mg medex with visa. In the eye discount medex 1 mg fast delivery, a focal type of choroiditis often affects both eyes and this is Toxocariasis usually at the posterior pole in the macular Toxocariasis is caused by Toxocara cati (from region. The diagnosis can be been found in the enucleated eyes of young conrmed by sending some blood for serologi- patients with a severe type of chorioretinitis. Four such tests are currently in use It is a unilateral disease found in children who clinically: the toxoplasma dye test, indirect are in close contact with puppies or eat dirt uorescent antibody test, haemaglutination test (through faecal contamination). These tests must be interpreted care- matory cells so that the presence of a tumour fully because a high proportion of the popula- might be suspected (e. End- tion becomes infected at some point and the ophthalmitis tends to develop in these cases and positive results increase with age, even in those the sight of one eye might be completely lost. For this During the acute stage, the peripheral blood reason, the diagnosis can be less easy in can show an eosinophilia. Treatment is un- acquired toxoplasmosis, where evidence of sys- satisfactory and includes a combination of temic involvement can be slight or absent. It has antihelminthic agent taken by mouth (thioben- been shown that there is a higher incidence of dazole or diethylcarbamazine) and steroids. The rela- Therefore, not all active toxoplasma retino- tionship seems less likely now that tuberculosis choroiditis lesions require treatment. Treatment is also required when there is and those with recalcitrant or atypical uveitis, severe vitritis. Choroidal tubercles are a well- diazine has been recommended, but such treat- described entity: these raised yellowish granulo- ment can cause a serious fall in the white cell matous foci were used as a diagnostic feature of count. An alternative antimicrobial treatment is miliary tuberculosis and, occasionally, chronic clindamycin. The choroiditis taneously, leaving more or less chorioretinal is more often peripheral and accompanied by The Inamed Eye 147 inammatory changes in the retinal veins. When the diagnosis is suspected, the conjunctiva and skin should be searched for possible nodules, which can be Behet s Disease biopsied, and an X-ray of the chest can reveal Behet s disease is a multisystem disease asso- enlargement of the hilar lymph nodes. It was originally thought management of the ophthalmological problem to occur only in the Mediterranean and Japan, might involve treatment with local and systemic where it is most common. It is characterised by steroids but the opinion of a physician special- an obliterative vasculitis. The clinical syndrome ising in sarcoidosis is essential and should be consists of oral and genital ulceration in com- sought before embarking on treatment. The uveitis consists of recurrent bilateral non- Presumed Ocular Histoplasmosis granulomatous anterior and/or posterior uveitis. Central nervous system involvement Histoplasmosis is a fungal infection (causative occurs as a serious form of the disease. A wide variety of infective agents have been Presumed ocular histoplasmosis is not seen shown to cause posterior uveitis on rare occa- in patients with active histoplasmosis. The leprosy bacillus and the coxsackie dence for infection in the originally described group of viruses are two examples chosen from cases was necessarily circumstantial hence the many. Sympathetic ophthalmia has already been expression presumed ocular histoplasmosis. An especially rare but intriguing form of haemorrhagic macular lesion (choroidal neo- uveitis is known as the Vogt Koyanagi Harada vascularisation) combined with discrete foci of syndrome, in which is seen the combination of peripheral choroiditis and peripapillary scars. Syphilis Syphilis is a chronic infection caused by Tre- The Role of Autoimmunity ponema pallidum. It is in Uveitis a bilateral disease in which the iris vessels are particularly engorged. Chorioretinitis can be Although it has been recognised for a long time either multifocal or diffuse and involves the that bacterial and viral infection can account mid periphery and peripapillary area. In the for some cases of uveitis, it has also been healed phase, perivascular bone spicule pig- recognised that the majority of cases fail to mentation could be seen similar to that show any evidence of this. The scat- which the uvea might be expected to become the tered pigmentation in the fundus might suggest focus of an antigen antibody reaction. A an inherited retinal degeneration but a careful foreign agent such as a virus might reside in the family history together with electrodiagnostic uvea and cause an antibody response, which testing of the eyes usually enables one to distin- coincidentally involves uveal tissue, or, on the guish the two conditions. It is also important to other hand, a foreign agent might react with a 148 Common Eye Diseases and their Management specic marker on the cell membrane to selected patients with toxoplasma retinocho- produce a new active antigen. The rationale of this treatment is to nised that patients who inherit certain of the destroy any remaining encysted organisms. A further way in which the uvea might become the centre of an When inammatory changes in the posterior immune response concerns the question of uvea extend into the vitreous and there is an self-recognition. It now appears that there is extensive involvement of the centre of the globe, a mechanism in the body that normally pre- the patient is said to have endophthalmitis. This active suppression anterior segment of the eye and into the sclera is maintained by a population of thymus- leads to panophthalmitis. Endophthalmitis is derived lymphocytes (T lymphocytes) known one of the feared results of infection after injury as T-suppressor cells. There is evidence to or surgery but it can prove reversible with inten- suggest that sympathetic ophthalmitis might sive antibiotic treatment. When endophthal- arise from inhibition of the T-suppressor cells mitis and panophthalmitis are not properly after uveal antigens have been introduced into and aggressively treated, the sight is usually the bloodstream. Patients with juvenile rheum- lost permanently and after months or years the atoid arthritis occasionally develop uveitis, whole eye begins to shrink. Episcleritis and Scleritis Management Both these conditions form part of the differen- tial diagnosis of the red eye. The episclera is the Increased interest in immunological diseases in connective tissue underlying the conjunctiva recent years, which has accompanied advances and it can become selectively inamed, either in tissue grafting and cancer research, has led diffusely or in localised nodules. In the case of to attempts to treat uveitis with means other episcleritis, close inspection of the eyes shows than steroids. The eye is red and can be gritty but supplement or replace steroids in difcult cases. Episcleritis is seen from time to If posterior uveitis is not due to any recognisable time in the casualty department and the infective cause,it is usual to start treatment with patient might be otherwise perfectly t and systemic steroids if the visual acuity becomes well. Such cases tend to recur and some develop signicantly impaired or if the lesion is close signs of dermatological disease. Large doses of systemic steroids tion responds to local steroids, but systemic are best administered on an inpatient basis, aspirin can also prove effective. This has the less common and more closely linked with added advantage of allowing a more detailed rheumatoid arthritis and other collagen dis- pretreatment examination and investigations, eases. The eye is red (diffuse or localised) and and often the opinion of a general physician or painful. The condition treated and immunosuppressive agents can be responds to systemic anti-inammatory agents, administered to resistant cases. When posterior particularly oral urbiprofen (Froben), which uveitis keeps recurring at the edge of previous can be supplemented with systemic steroids healed foci, laser coagulation has been used in and/or immunosuppressants. For dence of cataract in patients with chronic the elderly patient,it is often reassuring to know simple glaucoma, the association of macular that the problem is part of a normal process degeneration with cataract or glaucoma is rather than the result of a specic illness and more random. A high Changes in the Eyes with Age proportion of elderly people instill drops into their eyes, either prescribed for them or as The External Eye self-medication. Advising the elderly is often The eyelids tend to lose their elasticity and time consuming and might entail speaking to a become less rmly opposed to the globe. The younger relative or neighbour, but an adequate upper and lower lid margins become progres- explanation of the disease or problems will sively lower so that whereas in the infant the avoid anxiety and probably the need for further upper lid can ride level with or slightly above the subsequent unnecessary consultation. The rst can be the lower margin of the cornea and the lower cured, the second arrested or prevented, while lid. Some limitation of the ocular movements the third generally tends to run a progressive is accepted as normal in the elderly, especially course and treatment is unsatisfactory at limitation of upward gaze. The conjunctiva present, although signicant progress has been tends to become more lax and a thin fold of con- made recently. Attempts to measure the inci- junctiva might be trapped between the lids dence of these problems have produced a wide when blinking if this becomes excessive. Visual impair- the bulbar conjunctiva in the exposed region 149 150 Common Eye Diseases and their Management and the conjunctiva is especially prone to light reex is less marked. Arcus senilis is the name given to the circular white inltrate seen around the margin of the Eye Disease in the Elderly cornea. The lens gradually loses its plasticity throughout life and this results in a progressive The prevalence of blindness increases with age.

Formative research can be useful in developing programmes which are appropriate to the target population in terms of age generic medex 5mg line, gender buy generic medex 1 mg on-line, sexual experience and culture Make use of peer educators Place emphasis on promoting condom use purchase medex 5mg online, rather than abstinence generic 1 mg medex with visa. Telling people not to have sex is unlikely to be an effective intervention Are of appropriate duration. If undertaken in a planned way sexual history taking is an essential tool for risk assessment for targeted sexual health promotion work and for partner notification when indicated. While sexual health promotion activity is usually recorded in clinic notes, there is a need to develop a standard format for recording sexual histories, including sections on discussing prevention for both nurses and health advisers. In order to promote sexual health effectively a multi disciplinary team needs to: Recognise the importance of sexual health promotion Develop a shared philosophy Seek to develop trusting, non judgmental and respectful relationships with service users Be pro-active when appropriate Aim to develop consistency in messages and information regarding sexual health Have a clear understanding of the different roles within the team and refer appropriately Respect and value each others skills and experience Be keen to develop knowledge, skills and attitudes Recognise diversity amongst individuals and communities and aim to make the service accessible to all service users The key to developing health promotion within the clinic is the ability to work effectively as a multidisciplinary team. In order to achieve this, it is important that team roles in health promotion are clearly defined and co-ordinated and the different skills within the team are valued and maximised. If roles are not clearly defined there is a danger of either overloading the patient with advice or missing out health promotion altogether. Clear documentation of health promotion related discussion means that duplication can be avoided and team members can build on previous interventions. If members of the team are giving different messages about sexual health, for example risks of transmission attached to sexual activities patients will be confused and less likely to follow any advice given. While all clinic attendees are ideally given the opportunity to discuss prevention and related issues, it is important that team members use their skills and experience to assess the appropriateness, relevance and timing of any intervention. To fulfil this role doctors: Identify how they will fit explicit sexual health promotion routinely into their role Recognise that patients presenting with an infection or potential infection may be particularly receptive to sexual health promotion advice and harm reduction messages. The level of health promotion activity undertaken by the nurses will partly depend on acceptance within the clinic that this is part of their role. Issues of the amount of time the nurses spend with the patient and the lack of privacy for discussion also need to be taken into account. The health adviser will discuss safer sex with all patients and offer more in depth prevention work, where this is appropriate. It is therefore important that referral to health advisers be consistent and includes referral for in-depth prevention work based on a clear and consistent assessment process by other team members. Guidelines and protocols on which patients are referred to the health adviser need to be in place in all clinics with the aim of ensuring that those with particular issues around prevention receive the opportunity for in depth discussion, counselling and support. Particular consideration needs to be given to including referrals to health adviser that are specifically for prevention counselling, for example, exploring harm minimisation strategies. This will have an impact on the ability of health advisers to develop innovative and effective ways of working with different patient groups, including community outreach and support, but this also has clear resource implications. Receptionists While the reception team does not have a direct role in sexual health promotion, their importance as the first point of contact with the service ought not be underestimated. These may include the need for each clinic to: Have a clear protocol for clinic staff working with gay/bisexual men. Practitioners will benefit from having a good range of communication skills and techniques they can employ to work effectively with a variety of patients. Frameworks around the use of counselling skills The term counselling skills does not have a single definition, which is universally accepted. Although the distinction is not a clear one, because the term counselling skills contains elements of these other two activities, it has its own place in the continuum between them. In addition, members of the team (generally health advisers) with specific training and expertise would be able to offer (generally short-term) counselling sessions, where appropriate. One does not need a particular theoretical perspective in order to use counselling skills effectively, however what underpins the practice of both counselling and the use of counselling skills is: Confidentiality Respect for the patient s own perception of their experience Support for the person in finding their own solution to their difficulties In a health promotion context counselling skills can be used alongside other forms of interaction such as information and advice giving. A person centred approach to counselling 18 skills would generally be informed by Rogers three conditions for successful counselling. Both of these approaches are outlined in a number of books focusing on counselling/counselling skills, including Counselling: The Trainer s Handbook Francesca 20 Inskipp (1986) 21 Heron s Six-Category Intervention Analysis (Heron 1986) is a framework for identifying a range of possible interventions, and has often been used to explore the use of counselling skills within a health setting. As well as outlining the key points of this framework, nd 22 Counselling Skills For Health Professionals by Philip Burnard (2 edition 1994) offers a general overview of the use of counselling skills in a health setting including information about a range of theoretical stances. This model may be useful for doctors and nurses who are working within severe time constraints. This model offers the possibility of a routine structure in a consultation, even when taking a more patient centred approach. While expert information still has an important role to play it cannot stand-alone. The context of a person s life and relationships needs to be investigated and acknowledged if they are to be helped to develop their own personal strategy for sexual health. This model of sexual health promotion therefore takes less of a top- down approach than the medical model. The patient is brought clearly into focus and involved in an interaction with the doctor. The model could be represented as an equation: information on safer sex + the context of the client s life and relationships 24 = a personal strategy for sexual health. It identifies a change cycle, that each person will go through when considering behaviour change. The main elements of this cycle are: Not interested in changing Thinking about changing/deciding to try Trying to change/changing Relapse Miller and Rollnick suggest it is useful to identify where in the change cycle the patient is, and offer a range of approaches that are appropriate to each stage. This approach also recognises 300 the importance of ambivalence and resistance within the change process and encourages the practitioner to work with these issues without imposing their own agenda on the client. The Stages of Changing Behaviour (researched by Prochaska and DiClemente 1994) 27 identifies five stages individuals go through when they seek to change valued behaviour. These stages are: Pre-contemplation - not yet considering the possibility of change Contemplation - considers change and rejects it. Reasons for concern versus justifications for unconcern Planning and preparation - I ve got to do something about this problem Action Maintenance - identify strategies and support to prevent relapse This model would see relapse as a possibility within each stage of the cycle. Patients may step in and out of the cycle at any point like a revolving door, dependent on internal and external influences and their strategies for dealing with them. The process of harm reduction involves considering external guidelines and personal issues relating to the quality of life. The key stages of the harm reduction process are: Clarify the value attached to an activity Consider the risk attached to an activity Clarify how the value attached to the activity can be maintained while reducing the risk of the activity Consider what change is necessary to reduce the risk Harm Reduction is a model of behaviour change that can be useful in reflecting on change in highly valued behaviour. In a sexual health context this is a way of exploring the value and meaning that unprotected sex or risky behaviour might hold for the individual patient. Evidence has clearly shown that demonstrating condoms is effective and helps to minimise breakages, especially for younger and less experienced clinic attendees. Documentation ought to give the next practitioner an indication of the work / discussion that has taken place to avoid duplication of the same messages, and enable them to build on work previously undertaken. Mechanisms need to be identified and agreed for audit of sexual history taking, but this will only be able to be undertaken if sexual health promotion work has been clearly recorded in patient notes. Simply providing information is not enough to facilitate behaviour change for most people, but may provide a trigger for further work. Ideally each clinic has a leaflet group, for example a health adviser, nurse and doctor. These materials are largely provided from public health departments, and some targeted campaigns are sent directly to the clinic, either from the sponsors or direct from Health Promotion England. Referrals need to be patient centred, and take account of the fact that many people will feel ambivalent about referral to another agency. This ambivalence itself is an issue, which it may be appropriate to explore as part of the sexual health promotion process. Effective and appropriately timed referral will be facilitated if staff can give clear information about what the other service offers, explore and agree with the patient why they are making a referral, and how to access the service. It is important that clinics provide information about their services and hours of opening in a clear and accessible format. This information needs to be widely distributed to community settings, via appropriate local networks and mailings. It is important to have a named member of staff who may be identified to facilitate outreach information sessions within community settings to promote and explain the clinic service. Under represented audiences in clinics are ideally targeted, for example sex workers. A common approach to the use of interpretation and advocacy services for sexual health promotion work needs to be adopted. In order to increase access for people who are at work, school or college and cannot take time off during the day all clinics will need to work towards having at least one evening session available (open until 7. This may then be analysed by demographic data, for example for young heterosexual men. Nurses, doctors and health advisers should all be able to educate about condom use, and prompts/situations in which condom demonstration should always be provided should be clarified for all staff.

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Debate exists as plasma culture order medex 5mg, coliform count buy cheap medex 5 mg on-line, and cultures for other to whether milk samples for culture should be collected contagious forms of mastitis order medex 1 mg with amex. Currently the New York State tated before collecting the sample order medex 1 mg with mastercard, and it should be col- Mastitis Program recommends postmilking samples be- lected by a sterile dipper into the tank rather than from cause fewer contaminants occur in them. The teats the outlet valve, which might have a high concentration should be clean and dry. Public health concerns may dictate special culture Collection tubes should be sterile and held horizontally procedures. Bulk tank milk can be contaminated by with the cap downward to minimize contamination by zoonotic organisms such as Salmonella sp. After col- monocytogenes that may be concurrently causing other lection, milk should be stored at 4. On farm cultures of mastitis Bulk tank cultures may identify high numbers of spe- cases may be accomplished by Petrilm culture system. Usually acid-iodophor sanitizers diluted to a nal and the potential for successful lactation or dry cow concentration of 30 to 40 ppm iodophor and phosphoric therapy should be factored into all cull decisions. Iodine concentrations of 50 ppm have Veterinarians should encourage clients to enlist the been used but may cause ocular irritation to milkers. Al- services of mastitis control programs to aid them in in- kaline water and hard water decrease the effectiveness of terpreting results and institute programs to improve iodophor sanitizers. The use of backushing increases the amount of time that is re- quired for milking, and therefore some farms are reluc- Prevention and Control of Mastitis tant to use this procedure. However, the effectiveness of Milking Hygiene backushing for minimizing spread of contagious patho- Premilking hygiene can be accomplished by washing the gens has varied from farm to farm. The considerable cost teats with clean, uncontaminated water with or without of backushing technology has also contributed to its sanitizers or by predipping teats in an approved teat dip. Excessive wetting of the udder should be avoided because Postmilking teat dips are important for reducing new the owing water can carry bacteria down the teat and intramammary infections from contagious organisms into the milk, increasing the risk for new infection and and, to a lesser degree, from environmental pathogens. Washing should be done with indi- fections and will not affect the duration of existing infec- vidual towels, and milkers should wear latex or nitrile tions. Gloved hands should be rinsed and sanitized of- become contaminated after successive uses but must be ten during milking, especially when milkers hands be- carefully applied to completely contact the teat end. Iodine at 25 to 75 ppm application of teat dips will provide more effective and can be added to the wash solution. Teat dips provide superior automated group sprinklers or washers should allow the contact with the sphincter, but the contents must be udder and teat skin to dry for 10 to 15 minutes before replaced frequently to prevent contamination by envi- milking. Environmental bacteria are sus- iodine and complexing agents that establish equilibrium pended in the water droplets and increase the risk for but do not bind I2 molecules. Common washing solu- the active form and continue to be released from the tions, sponges, or rags should not be used because of the complexing agent as the solution is used. Use of a common very effective against contagious pathogens when used washcloth is a well-established cause of cow-to-cow as a 1% or 0. Lower strength iodophor dilu- transmission of contagious forms of mastitis including tions also may be effective and are less irritating to tissue S. This procedure may be es- tains a bibliography of premilking and postmilking teat pecially effective at reducing new coliform and S. Some germicides may harbor pathogenic when used on cows in their rst and second lactations. It is critical teat for 20 to 30 seconds before being wiped away with that teat dippers be cleaned and sanitized daily. Proper contact time Physical barrier dips made of latex and acrylics are and removal of the predip to avoid residual iodine con- among the other products marketed to reduce the risk tamination of milk are essential. Barrier dips must be care- action of oxytocin release to make this fraction harvest- fully removed before the next milking to avoid con- able in a timely manner. Teat dip should be required to stimulate the release of oxytocin from the stored carefully to avoid either freezing or exposure to pituitary gland. Freezing of dips has caused separa- stimulation of milk let down is referred to as the prep- tion of the contents or layering that rendered the solu- lag time. Forestripping three backushing, and dipping results in less than 500 g/L squirts of milk from each teat provides the best oppor- iodine residue in milk. It is believed that a time of 60 to 90 seconds is milking procedures, hygiene, and mastitis prevalence. Adequate prep-lag time is dip programs that have been effective should not be created by organizing other premilking procedures in- changed. When used in accordance with the label instruc- cluding predipping, cleaning, and drying teats in a man- tions, most teat dip programs decrease new intramam- ner that creates the optimal prep-lag time. When environmental pathogens are the major uence the development of teat-end hyperkeratosis, mastitis problem, barrier dips and predipping may be which is a recognized risk for new infections if teat-end considered. Characteristics of milk ow from a tures or wind chill predispose to frostbite, teat dipping properly prepared cow include a rapid increase to peak with aqueous solutions may be suspended. Suspending ow and maintenance of a relatively uniform peak ow postmilking teat dipping may place the herd at greater risk until the cow is milked out. The initial increase in the for new infections particularly if contagious pathogens milk ow rate and peak ow is strongly inuenced by the (S. In these situations, rapid drying dips are phase of milk ow is largely an individual cow character- best to avoid damage to the teat end. The rst milk to be harvested immediately after polypropylene glycol to teat dips prevents excessive drying the milking unit is attached is cisternal milk. If stimulation of let down is inad- lowing milking to keep them standing until the teat end equate or prep lag time is short, milk ow into the claw dries and the streak canal closes completely. This tech- will decrease substantially or cease for a period after nique helps to avoid environmental contamination of the cisternal milk is harvested (often a minute or more), teat ends immediately after milking. Milk ow graphs below were generated with the dures on milk harvest efciency and udder health have LactoCorder. Studies have shown that premilking A basic understanding of the milking machine and stimulation provided by forestripping, washing, and equipment is essential when evaluating mastitis or milk wiping of teats, and the time interval required to take quality problems on a dairy. Improperly functioning full advantage of oxytocin release and milk let down machines may contribute to the spread of contagious leads to greater peak milk ows and shorter unit on pathogens, create new infections by environmental or- time. It ow of milk at the teat end, thereby predisposing to accounts for approximately 20% of stored milk and is mastitis. Bimodal milk ow results in inefcient milk harvesting by extending machine-on time. The extended machine-on time results in overmilking and excessive trauma to teat ends, which may increase teat end hyperkeratosis and the risk for new mastitis infections. Although slight differences exist, the Reduced milk ow toward the end of milking may be major principles and techniques are very similar. Poorly caused by obstruction of ow from the gland cistern to the functioning or poorly maintained milking systems and teat cistern as the vacuum inside the liner pulls the teat machines may contribute to teat-end injuries, the spread deeper into the liner. Poorly results in teat-end injury because massage is less effective cleaned equipment may contribute to high bulk tank at counteracting the congestion and trauma to the teat end bacterial counts and postpasteurization counts. Vacuum uctuations cyclical vacuum uctuations bore to maintain a snug t along the entire length of the may occur in the claws or liner and often correlate teat and lessen the chances of liner slips, air leaks, or teat with improper pulsator function or inadvertent cups that ride too high on the teat. The Decreased vacuum during the massage phase may inside of the liner is under constant vacuum from the short result in teat end trauma, and subsequent reduction milk tube from the claw. During milking, the liner maintains its normal milking phase may initiate reverse milk ows and shape. The opening of the streak canal that allows milk to droplet jets that spray against the teat ends. Milk ow into the liner is primarily caused by the vacuum that ow reversal may force pathogens into or through is applied at the teat end. When the cavity is vented to atmo- systems with low milk lines and should not ex- spheric pressure, negative pressure at the teat end collapses ceed 15 in Hg for high milk lines. The volume of air displaced at a given vacuum end would produce edema and blood engorgement of the level is expressed in cubic feet per minute walls. Current recommendations for reserve increases the milk ow during the next milking cycle. This may vary slightly with various milk- milkout is less efcient during the latter phase of milking. Pulsator line sizes: Cracked or damaged liners are difcult to clean and 1 to 2 in for up to 6 units disinfect. They act as reservoirs for pathogens and do 2 to 3 in for 7 to 15 units not function properly during milking.

Health care and medical treatment Prison Service Health Care Standards have the stated aim " to give prisoners access to the same quality and range of health care services as the general public receives from the National 16 Health Service" buy medex 1mg. The European Prison Rules state " the prison medical services should be organised in close 17 relation with the health administration of the community or nation" purchase medex 5mg. Harm reduction and prevention Drug use Those with drug problems will often be placed on a detoxification wing purchase medex 1 mg line, and weaned off discount 5 mg medex otc. This presents an ideal opportunity to address information on harm reduction, safer injecting practices and maintenance of behaviour outside prison. It is not current prison service policy to provide needles and injecting equipment, but this is kept under regular review. Disinfectant tablets for sterilisation of equipment are to be implemented throughout the prison service in 2004, as recommended by the Aids Advisory 19 Committee. Condom use There has been significant debate about the issuing of condoms in prisons, as the present law prohibits sex between men except that which occurs in a private place between 2 consenting men aged 18 or over. However, prison policy confirms that the cell is a private place, and an illegal act would not be taking place. In 1996, doctors were given authority to distribute condoms to those at risk of infection and prison policy encourages all governors to introduce schemes where condoms are available upon release. It is also recommended that dental dams be made available in women s prisons, but again there is little information on the extent or 20 nature of sex between women in prisons. There is need for more research into the needs of prisoners and systematic collection of information on risk practices. It may be the most stable time for a prisoner, where some support is available and the prisoner has time to reflect on their behaviour. Prisoners will be restricted in time or place as to when and where they can be seen. There may be considerations about the appropriateness of testing and how results are accessed for a prisoner, especially if they are on remand or transferred at short notice. There may be other social or psychological issues that prevent a prisoner making decisions about their health, and sexual health may not be a priority. Opportunities for support may be more limited, both formal and informal, and prisoners may be isolated or separated from usual forms of support from friends or family. There may be particular problems for achieving and maintaining sexual and drug-using behaviour change both in prison and on release. Precarious coping mechanisms of some prisoners may lead to more impulsive or risky behaviour. The Criminal Justice Act 1991 puts the throughcare of prisoners on a statutory footing. All adult prisoners sentenced to 12 months or longer, and all young offenders will be released on licence and subject to supervision by the probation service. Therefore, establishing a multidisciplinary policy approach will help prevent management problems and ensure consistency and appropriate interventions. The aim is to provide a throughcare system offering an outcome at least as good as that available outside prison. The National Aids Manual also has general advice and information on prisons and prisoners, as well as advice for 23 partners and families of prisoners. It is important to respect prison rules and avoid the following: Use of mobile phones The supply of unauthorised items or gifts to prisoners Allowing prisoners to use phones or be alone in offices Any breach of security may have serious consequences for the prisoner and may cause difficulties for other agencies coming into the prison. Working with staff It is important to work with the prison staff to break down any misconceptions on either side. Good networking is essential in the care of the inmate - it is important to know when they may be going to court, if they are going to be transferred or released. Working with prisoners If a prisoner has an appointment outside, two officers, usually, will accompany them. The understanding is that unless the prisoner is a significant risk, the confidentiality of any medical consultation will be respected, and the prisoner allowed to be uncuffed. It is important to be aware that appointments may be cancelled at very short notice often due to shortage of officers to transport the prisoner. The counselling environment is very different - there may be restrictions on time and place, and the inmate will not necessarily be advised of their next appointment especially if it is outside the prison. It is important to encourage prisoners to use other services and try to identify sources of support, for example a particular wing officer, other prisoners, probation officer or psychologist. If seeing a prisoner without a chaperone, general health and safety rules apply such as location of emergency buzzer and seating arrangements in the room. In the national survey of sexual attitudes and lifestyles in 1994, it was found that 8. The prison sample reports much higher rates than this but direct comparisons with national data are difficult. It may be more difficult to resolve partner notification, but there is usually a medical officer to whom information can be passed on and they can call the prisoner down for a check-up without compromising confidentiality. An understanding of the theories and definitions of health and health promotion are essential to good practice. The Ottawa charter is presented as a framework for health promotion within the health adviser role. Their 1985 discussion paper of the principles health promotion contains the following useful definition: Health is, therefore seen as a resource for everyday life, not the objective of living; it is a positive concept emphasising social and personal resources, as well as 2 physical capacities. This he argues work for health must be enabling, allowing individuals to build on their foundations. Seedhouse believes that health workers are under the spell of medicine and remain bound to the medical model. He argues that the problem is the popular view of health as beginning 4 with disease and not as a quality in its own right. Other writers have argued that the problem is that health workers are often accountable to clinicians. If medical personnel set priorities, then the health promoter is often required to 5 concentrate on the medical flavour of the month. Tannahill describes an experience of teaching medical students; when he asked them to define health they suggested the absence of clinical signs. However, when they were asked to define their own personal health they were concerned with self esteem, physical fitness and mental and social well being. When asked to consider the dilemma of straight jacketing patients within a medical definition, yet defining their own health in positive terms, they could 6 offer no defence. With such flexible and broad definitions of health, the problem for health promoters can be in essence deciding what to promote. If health encompasses a broad spectrum of well being, including psychological and social, confusion and conflict of interest can arise. Health professionals of all disciplines, and even those working in other agencies such as welfare, could make the case that they do health promotion, particularly if they believe that resources 7 will be allocated as a result. An example is given by Yeo, whereby a Canadian health department guidelines document places transplant programmes under the heading of health promotion. There has been much debate about what makes it a unique activity whereby some tasks will fall within the criteria laid out in accepted theory. There has been a paradigm shift in recent years from health education to health promotion. Health education became tainted with the criticism that it was tantamount to victim blaming. Tannahill describes health promotion as three spheres of activity, health education, health 8 9 10 protection and prevention. Other theorists, such as Seedhouse, Tones and French also subscribe to the idea of health education being the teaching arm of health promotion. French contends: Health Education is a practical endeavour focused on improving understanding about the determinants of health and illness and helping people to develop the skills they need to bring about change. Health Promotion is a convenient conceptual tool which enables us to order our understanding of those often diverse elements within 11 society that have the potential to promote health. For health educators it became untenable to continue to simply promote lifestyle change, particularly as the Report demonstrated a link between poverty and heart disease. This added to the growing discomfort about health education programmes that merely stressed behaviour change.

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